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Hibrarp 


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Th^  Students'  Quiz  Scries. 


QYNECOLOGY. 


A  MANUAL  FOR  STUDENTS  AND  PRACTITIONERS. 


BY 

G.  W.  BRATENAHL,  M.  D., 

Assistant  in  Gynecology,  Vanderbilt  Clinic,  New  York, 
AND 

SINCLAIR  TOUSEY,  M.  D., 

Assistant  Surgeon,  Out-Patient  Department,  Roosevelt  Hospital,  New  York. 


SERIES  EDITED  BY 

BERN   B.  GALLAUDET,  M.D., 

Demonstrator  oj  Anatomy,  College  of  Physicians  and  Surgeons,  New  York ;  Visiting 
Surgeon  Bellevue  Hospital,  New  York. 


PHILADELPHIA : 
LEA  BROTHERS  &  CO. 


Entered  according  to  Act  of  Congress,  in  the  year  1892,  by 

LEA   BROTHERS  &  CO., 

In  the  Oflace  of  the  Librarian  of  Congress,  at  Washington.    All  rights  reserved. 


"KG- 1" 


Westcott  &  Thomson,  William  J.  Dornan, 

Stereolijpers  and  Electrotypers,  Philuda.  Printer,  Philada. 


PREFACE 


In  compiling  this  quiz  compend  we  have  discussed  the  various 
diseases  which  affect  the  female  generative  organs,  in  the  order  of 
the  anatomical  position  of  the  latter,  beginning  at  the  vulva ;  and 
we  have  given  under  each  heading  as  complete  a  resume  of  the 
subject  as  possible  in  the  space  at  our  disposal.  As  our  authori- 
ties we  are  indebted  to  the  works  of  the  following  authors,  and 
to  notes  taken  from  the  lectures  of  Prof.  G.  M.  Tuttle :  Pozzi, 
Thomas  and  Munde,  Mann's  System^  Martin,  Schroeder,  Shultze, 
Hegar  and  Kaltenbach,  Skene,  and  Hart  and  Barbour. 

It  is  hoped  that  the  compend  will  prove  of  service  both  to  the 
student  and  to  the  practitioner  who  wishes  to  refresh  his  memory 
upon  some  of  the  more  important  features  of  gynecology. 

G.  W.  BRATENAHL, 
SINCLAIR  TOUSEY. 


CONTENTS 


PAGE 

Causation  of  Gynecological  Disease 17 

Diagnosis  of  Gynecological  Disease  :  Eational  Examination ; 
Physical  Examination  ;  Inspection  ;  Touch  ;  Bimanual  Examina- 
tion ;  Sounds ;  Steel  and  Hard-Kubber  Sounds ;  Steel  Branched 
Dilators;  Dilatable  Tubes;  The  Curette  as  a  Diagnostic  Agent  .    .      IS 

External  Organs  of  Generation  :  Anatomy 40 

Diseases  of  the  Vulva:  Malformation;  Tumors  and  New  Growths; 
Inflammations ;  Nervous  Affections  of  the  Vulva ;  Irritable  Urethral 
Caruncle ;  Coccygodynia  or  Coccyodynia ;  Prolapsus  Urethrse    .    .      45 

Diseases  of  the  Vagina  :  Inflammations  of  the  Vagina ;  Vaginal 
Cysts ;  Vaginal  Ulcers  ;  Malformations  of  Vagina ;  Displacements 
of  the  Vagina ,..-....      57 

The  Perineal  Body  and  Pelvic  Floor:  Anatomy;  Lacerations 

of  the  Perineum  and  Pelvic  Floor ;  Operations 65 

The  Urethra  and  Bladder  :  Anatomy ;  Diseases  of  the  Urethra 

and  Bladder 77 

The  Internal  Organs  of  Generation 84 

Diseases  of  the  Uterus  :  Anatomy ;  Malformations  and  Diseases 
of  the  Uterus ;  Hypertrophy ;  Atrophy ;  Displacements  of  the 
Uterus;  Anteversion ;  Anteflexions;  Eetroversion  and  Retro- 
flexion; Pessaries;  Descent  and  Prolapse  of  the  Uterus;  Acute 
Metritis;  Chronic  Metritis ;  Applications  through  the  Speculum; 
Endometritis ;  Acute  Endometritis ;  Chronic  Endometritis ;  Chronic 
Corporeal  Endometritis ;  Chronic  Catarrh  of  the  Cervix  (Chronic 
Cervical  Endometritis) ;  Laceration  of  the  Cervix 84 

Neoplasms  of  the  Uterus:  Fibroid  Tumors,  or  Fibro-myomata ; 
Subserous  Fibroids ;  Interstitial  Fibroids ;  Submucous  Fibroids ; 
Fibro-cystic  Tumor  of  the  Uterus ;  Uterine  Polypus ;  Carcinoma 
of  the  Uterus;  Adenoma  of  the  Uterus;  Sarcoma  of  the  Uterus  .    .    I4G 

5 


6  CONTENTS. 

PAGE 

Inversion  of  the*  Uterus:  Amputation  of  the  Uterus 165 

Diseases  of  the  Ovaries:  Anatomy  of  the  Fallopian  Tubes  and 
Ovaries ;  Malformation  of  the  Ovary ;  Atrophy  of  the  Ovaries ; 
Displacements  of  the  Ovary ;  Ovarian  Apoplexy  ;  Inflammations 
of  the  Ovary ;  Abscess  of  the  Ovary ;  Neoplasms  of  the  Ovary ; 
Dermoid  Cyst  of  the  Ovary ;  Ovarian  Cysts ;  Cysts  of  the  Broad 
Ligament,  or  Parovarian  Cysts ;  Laparotomy  for  the  Eemoval  of 

the  Uterine  Appendages  or  of  Cysts 170 

Diseases  of  the  Fallopian  Tubes:  Salpingitis;  Pyosalpinx; 
Hsematosalpinx ;    Laparotomy   for   Pyosalpinx,   etc.,    "  Salpingo- 

Oophorectomy " 185 

Extra-uterine  Pregnancy 187 

Diseases  of  the  Pelvic  Peritoneum  and  Fascia  :  Pelvic  Peri- 
tonitis ;  Pelvic  Cellulitis  or  Parametritis ;  Pelvic  Ha^matocele  and 

Hsematoma 188 

Menstruation  :  Disorders  of  Menstruation 1 99 

Electricity  in  Gynecology = 206 


GYNECOLOGY. 


CAUSATION  OF  GYNECOLOGICAL  DISEASE. 

What  are  the  chief  causes  of  gynecological  diseases  ? 
They  may  be  divided  into  predisposing  and  exciting. 
Predisposing  Causes : 

(1)  Neglect  of  out-door  exercise. 

(2)  Imprudence  during  menstruation,  such  as  violent  exercise 
at  the  menstrual  period,  going  out  too  lightly  clad,  or  getting  wet 
feet,  which  result  in  cessation  of  the  menstrual  flow,  endometritis, 
and  other  inflammatory  conditions,  with  subsequent  dysmenorrhoea, 
sterility,  pelvic  pain,  etc. 

(3)  Undue  mental  work  during  the  period  when  the  generative 
organs  are  developing,  resulting  in  malnutrition   of  these   organs. 

(4)  Improprieties  of  dress,  such  as  tight  lacing,  having  skirts 
suspended  at  the  waist,  resulting  in  uterine  displacements  and  con- 
gestive disturbances. 

(5)  Improper  postures,  such  as  too  much  sitting  down,  sewing- 
machine  work,  high-heeled  shoes  tilting  the  body  forward,  etc. 

(6)  Prevention  of  conception. 

(7)  Improper  care  or  neglect  during  parturition. 

(8)  Induction  of  abortion. 

(9)  Marriage  with  existing  uterine  diseases. 
(10)  Habitual  constipation. 

Exciting  Causes : 

(1)  Injuries  at  parturition,  lacerations  of  the  cervix  and  peri- 
neum, pudendal  and  subperitoneal  haematocele,  inversion  of  the 
uterus. 

(2)  Derangements  of  involution,  subinvolution,  superinvolution, 
retention  of  foetal  envelopes,  displacements  of  the  uterus. 

(3)  Congenital  anomalies. 

(4)  Sudden  violent  efl"orts,  producing  flexions,  versions,  and 
prolapse. 

2— Gyn-  17 


18  DIAGNOSIS   OF   GYNECOLOGICAL   DISEASE. 

(5)  Neoplasms  developing  in  the  genital  tract. 

(6)  General  peritonitis,  producing  deposits  of  lymph  in  the  pel- 
vis, and  thereby  displacements  of  the  uterus. 

(7)  Local  treatment,  sounds,  tents,  etc. 

(8)  Gonorrhoea. 

(9)  Syphilis. 

(10)  Means  adopted  in  criminal  abortions. 

DIAGNOSIS  OP  GYNECOLOGICAL  DISEASE. 

What  are  the  means  employed  in  attaining  a  diagnosis  of  gyne- 
cological diseases? 

1st.  Rational  testing  of  patient ; 
2d.  Physical  examination. 

RATIONAL  EXAMINATION. 

What  questions  should  be  asked  in  taking  a  history? 

Name  ?  Age  ?  Occupation  ?  Residence  ?  Married  ?  Single  ? 
Widow?  If  married,  how  long?  Number  of  children?  First? 
Last  ?  Labors  easy  or  instrumental  ?  Number  of  miscarriages  ? 
Last  ? 

Age  when  first  appeared  ; 
Type; 
Duration  ; 
Amount ; 
^  Pain  before,  during,  after. 

C  Character ; 
Leucorrhoea  ?        -j  Amount ; 
(^  Constancy. 

C  Locality  ; 
Pain  ?  -j  Degree  ; 

(^  Character. 

Bladder:  Micturition,  whether  frequent  or  painful? 
Bowels?     Previous   and  family  history?     Duration  of  present 
illness  ?     Chief  symptoms  ? 

PHYSICAL   EXAMINATION. 

What  means  are  employed  in  making  a  physical  examination? 

(1)  Inspection  ;  (2)  vaginal  touch  ;  (3)  bimanual  manipulation  ; 


Menstruation  ?      < 


PHYSICAL   EXAMINATION.  19 

(4)  rectal  touch ;  (5)  abdomino-rectal  exploration ;  (6)  abdominal 
palpation ;  (7)  speculum ;  (8)  sound  and  probe ;  (9)  abdominal 
palpation,  with  use  of  sound;  (10)  tents  and  dilators;  (11)  dull 
curette ;  (12)  exploring  needle  and  aspirator ;  (13)  microscope ; 
(14)  auscultation  and  percussion. 

Describe  the  method  of  making  an  examination. 

A  table  covered  with  a  blanket  and  provided  with  a  small  pillow 
should  always,  when  practicable,  be  employed  for  examinations, 
instead  of  a  bed  or  lounge.  The  patient  should  lie  upon  her  back, 
with  the  knees  well  drawn  up  and  abducted.  A  sheet  should  be 
spread  over  her,  so  as  to  conceal  the  entire  person  except  the 
vulvar  region.  When  a  table  is  impracticable,  the  patient  should 
be  placed  crosswise  on  her  bed,  the  nates  close  to  the  edge,  and  the 
knees  drawn  up. 

INSPECTION. 

What  is  the  diagnostic  value  of  inspection  ? 

By  a  thorough  examination  of  the  external  genitals  we  may  find 
enlargements  of  the  labia  majora,  nymphae,  or  clitoris ;  mucous 
patches  and  ulcers  ;  pediculi  pubis  ;  character  of  the  vulvar  mucous 
membrane,  whether  inflamed  or  not,  or  violet-colored  as  in  preg- 
nancy. We  note  the  condition  of  the  perineum,  whether  lacerated 
or  not;  protrusion  of  the  vaginal  walls;  urethral  caruncle;  cha- 
racter of  any  discharge  coming  from  the  vagina ;  condition  of  the 
hymen.  Examine  the  orifices  of  Bartholin's  glands  ;  note  whether 
reddened  or  not  (a  point  in  the  diagnosis  of  gonorrhoeal  inflamma- 
tions). Feel  for  enlargements  of  the  glands  themselves.  Inspec- 
tion of  the  abdomen  will  reveal  the  shape  and  size  of  a  suspected 
tumor. 

VAGINAL   TOUCH. 

What  are  the  steps  in  performing  a  vaginal  or  a  digital  examina- 
tion? 

The  patient  having  been  placed  on  her  back  as  described,  the 
index  finger  of  either  hand  is  anointed  with  vaseline  and  introduced 
into  the  vagina  from  below  up  over  the  perineum,  never  from  above 
downward.  The  other  fingers  are  strongly  flexed  into  the  palm,  while 
the  thumb  lies  on  the  symphysis  between  the  thighs.  In  married 
women  two  fingers,  the  index  and  middle,  are  employed,  and  intro- 


20  DIAGNOSIS   OF   GYNECOLOGICAL   DISEASE. 

duced  backward  into  the  hollow  of  the  sacrum  until  the  cervix 
is  reached. 

Fig.  1. 


Showing  the  Position  of  the  Hand  in  Digital  Examination  (Hart). 

What  conditions  are  sought  for  during  this  examination  ? 

(1)  Thickness  of  the  perineal  body,  as  determined  by  approxi- 
mating the  thumb  and  index  finger ;  presence  or  absence  of  painful 
spots  or  spasm. 

(2)  Presence  or  absence  of  rugae  in  the  vaginal  wall ;  relaxation 
of  the  latter ;  note  whether  dry,  moist,  or  hot ;  tumors  of  the 
vaginal  wall  or  foreign  bodies ;  presence  of  faeces  or  tumor  in  the 
rectum. 

(3)  The  cervix  being  reached,  place  the  palmar  surface  of  the 
finger  against  the  os ;  note  direction,  shape,  size,  consistence,  and 
mobility  of  the  cervix  ;  character  of  the  surface,  whether  soft  and 
velvety  or  roughened  ;  note  character  of  the  os,  whether  lacerated, 
stenosed,  or  patulous  ;  note  bodies  projecting  through. 

(4)  Passing  the  finger  along  the  posterior  surface  of  the  cervix 
into  the  posterior  fornix,  any  tumor  or  hardness  there  should 
be  noted. 

What  may  be  felt  through  the  posterior  fornix  ? 

(1)  Pieces  in  the  rectum  ; 

(2)  Acute  or  chronic  inflammatory  deposits  ; 

(3)  Retroverted  or  flexed  fundus  uteri ; 

(4)  Blood  eff"usions ; 


PHYSICAL    EXAMINATION.  21 

(5)  Fibroids  attached  to  the  posterior  wall ; 

(6)  Ovary  and  tube  prolapsed,  inflamed,  or  cystic  ; 

(7)  Ascitic  fluid ; 

(8)  Extra-uterine  foetation ; 

(9)  Retro-uterine  and  peritoneal  abscess  ; 

(10)  Thickened  and  tender  utero-sacral  ligaments  ; 

(11)  Hydatid  cysts  and  dermoid  cysts  (rare). 

What  may  be  felt  through  the  anterior  fornix? 

The  fundus  of  a  normal,  anteverted,  anteflexed,  or  pregnant 
uterus ;  angle  between  the  body  and  cervix  normally  ;  fibroids ; 
inflammatory  or  blood  affusions ;  tender  ovaries  (rare).  A  full 
bladder  gives  the  sensation  of  a  cystic  tumor  here. 

What  may  be  felt  in  the  lateral  fornices? 

Tumors,  fibroids,  cysts,  etc. ;  dilated  Fallopian  tube  ;  tubal  preg- 
nancy ;  exudation  masses ;  cellulitis,  peritonitis ;  blood  effusions 
into  the  broad  ligaments ;  prolapsed  and  enlarged  ovaries  and 
tubes ;  latero-flexed  uterus. 

BIMANUAL  EXAMINATION. 

Describe  bimanual  examination. 

This  combines  vaginal  touch  with  abdominal  palpation.  The 
patient  is  placed  as  before,  and  the  fingers  introduced  until  the 
cervix  is  reached.  The  palmar  surfaces  of  the  fingers  are  then 
placed  against  the  os  externum  and  pushed  upward  toward  the 
abdominal  wall.  At  the  same  time  the  external  hand  is  placed  on 
the  abdomen  just  above  the  symphysis,  and  a  steady,  gentle,  but 
firm  pressure  is  made  with  the  balls  of  the  fingers,  the  patient  being 
told  to  breathe  quietly,  keep  her  mouth  open,  and  relax  the  abdom- 
inal muscles.  In  this  manner  an  attempt  is  made  to  approximate 
the  internal  and  external  fingers,  and  any  intervening  structures 
can  be  accurately  mapped  out.  It  is  well  to  have  a  definite  order 
to  follow  in  making  a  bimanual  examination  :  First  push  up  the 
cervix,  and  if  the  uterus  is  in  its  normal  position  the  fundus  will 
come  in  contact  with  the  abdominal  hand  and  a  transmitted  motion 
will  be  felt.  Next  pass  the  internal  fingers  into  the  anterior  fornix, 
and  note  any  transmitted  motion  from  a  body  felt  here  ;  this  would 
be  the  fundus  normally  and  in  antepositions.  Next  pass  back  into 
the  posterior  fornix,  behind  the  cervix,  and  continue  the  attempt  at 
approximation  of  the  two  hands.     In  the  same  way  the  lateral  for- 


22 


DIAGNOSIS   OF   GYNECOLOGICAL    DISEASE. 


nices   are  thoroughly  palpated.     The  right  hand  should  be  used 
internally  for   the   right  side,  and  the  left  for  the  left  side.      The 

Fig.  2. 


Position  of  the  Hands  in  a  Bimanual  Examination. 

most  important  step  is  first  to  ascertain  the  exact  position,  shape, 
and  size  of  the  uterus :  after  this  the  lateral  fornices  can  be  pal- 
pated, using  the  uterus  as  a  landmark. 

Describe  the  method  of  performing  a  rectal  examination. 

(1)  Tell  the  patient  what  is  going  to  be  done. 

(2)  Scrape  soap  under  the  finger-nail  and  anoint  the  finger  with 
vaseline. 

(3)  Introduce  the  finger  slowly,  first  forward,  then  upward. 

What  should  be  noted  in  this  examination? 

(1)  P]xistence  or  absence  of  hemorrhoids. 

(2)  Fissures,  fistular  ulcers,  strictures  (specific  or  malignant), 
polypi. 

Note  position  and  size  of  cervix,  posterior  uterine  wall,  position, 
etc.  of  ovaries,  existence  of  tumors. 

Ahdominal-rectal  examination  combines  the  above  with  pressure 
from  the  hand  on  the  abdomen,  as  in  bimanual  examination. 


PHYSICAL    EXAMINATION. 


23 


Where  is  this  method  particularly  valuable  ? 

In  virgins  and  where  the  abdominal  wall  is  rigid. 

Recto-vagino-ahdoininal  examuiadon  combines  the  middle  finger 
in  the  rectum,  the  index  finger  in  the  vagina,  and  the  other  hand 
on  the  abdomen. 

What  is  Simon's  method? 

The  introduction  of  the  whole  hand  into  the  rectum.  This  is  a 
dangerous  practice,  and  is  very  seldom  required. 

SPECULA. 

What  are  the  three  main  forms  of  specula  ? 

(1)  Spatular — Sims's  and  Simon's  speculum. 

(2)  Tubular — Fergusson's. 

(3)  Bivalve — Brewer's,  Cusco's. 

Describe  the  Sims  or  duckbill  speculum. 

This  is  composed  of  two  blades,  set  at  right  angles  to  an  inter- 
mediate handle.     Each  blade  is  concave  on  the  outer  aspect  and 

Fig.  3. 


Sims's  Speculum. 

convex  on  the  inner.     Usually  one  blade  is  shorter  and  smaller 
than  the  other. 

What  is  the  Sims  position? 

The  patient  lies  on  her  left  side  and  chest,  with  the  left  arm 
behind  her  over  the  edge  of  the  couch  or  table  ;  the  hips  close  to 
the  edge ;  knees  well  drawn  up  ;  and  the  upper  knee  touching  the 
table  with  its  inner  aspect. 


24  DIAGNOSIS   OF   GYNECOLOGICAL    DISEASE. 

How  is  the  Sims  speculum  introduced? 

The  bhide  to   be  introduced  is  warmed  and  oiled  on  its  convex 
aspect ;  the  labia  are  separated  with  the  fingers  of  the  left  hand. 

Fig.  4. 


Simon's  Specula. 


The  blade  is  then  grasped  in  the  right  hand,  with  the  index  finger 
lying  in  the  concave  surface,  and  passed  into  the  vagina  over  the 
perineum  backward  toward  the  hollow  of  the  sacrum,  as  far  as  the 
posterior  fornix  behind  the  cervix.  Traction  is  now  made  by  an 
assistant  backward,  elevating  the  posterior  vaginal  wall,  and  the 


PHYSICAL    EXAMINATION. 
Fig.  5. 


25 


Cleveland's  Self-retaining  Speculum. 


internal  extremity  is  tilted  somewhat  forward.     The  anterior  vaginal 
wall  is  depressed  with  a  depressor,  and  the  cervix  brought  into  view. 

How  should  the  speculum  be  held  ? 

(1)  The  outside  blade  can  be  grasped  by  the  right  hand  of  the 


26 


DIAGNOSIS    OF    GYNECOLOGIC^AL    DISEASE. 


assistant  from  below,  with  the  thumb  extended  along  the  concave 
surface  and  over  the  angle. 

(2)  Another  and  easier  method  is  to  grasp  the  handle  from 
below,  the  angle  of  the  speculum  lying  in  the  hollow  between  the 
thumb  and  forefinger,  and  the  convexity  of  the  blade  resting  on  the 
dorsum  of  the  hand.  The  upper  labia  and  buttocks  of  the  patient 
are  elevated  by  the  left  hand  of  the  assistant. 

Describe  the  Simon's  speculum. 

This  is  composed  of  several  blades,  varying  in  shape  and  size, 
capable  of  being  fastened  to  a  handle.  They  are  introduced  as  a 
Sims  speculum,  either  in  the  dorsal  or  Sims  position  or  in  Simon's 
position. 

Describe  the  the  Cleveland  self-retaining  speculum. 

It  is  composed  of  double  blades,  which  are  held  in  position  by  a 
broad  band,  with  a  buckle,  passed  over  the  patient's  shoulder.  It 
is  introduced,  as  is  a  Sims  speculum,  in  the  Sims  position. 

Describe  the  Fergusson  speculum. 

This  is  the  best  form  of  the  tubular  variety,  and  consists  of  a 
glass  or  hard-rubber  cylinder,  trumpet-shaped  at  one  end  and  bev- 

Fi«.  G. 


Fergusson's  Speculum. 

elled  at  the  other.  It  is  from  four  to  five  inches  long,  and  comes 
in  sets  of  three  or  four  of  suitable  sizes.  When  made  of  glass  it  is 
silvered  internally  and  covered  with  caoutchouc  externally. 

Describe  the  mode  of  introduction. 

The  speculum,  being  warmed  and  oiled,  is  grasped  by  the  trum- 
pet end  in  the  right  hand,  the  labia  are  separated,  and  the  bevelled 
extremity  passed  into  the  vaginal  orifice,  short  side  to  the  front. 
The  perineum  must  be  well  depressed  and  the  instrument  pushed 


PHYSICAL    EXAMINATION. 


27 


slowly  backward  until  arrested.  The  cervix  is  brought  into  view 
by  drawing  the  instrument  out  a  little  and  pushing  it  back  in 
various  directions,  at  the  same  rotating  it.  The  dorsal  or  Sims 
position  may  be  used. 

What  are  the  uses  of  this  speculum  ? 

In  applications  to  the  cervix,  endometrium,  and  vagina.  It  can- 
not be  used  in  operations  upon  the  cervix  or  vagina,  and  its  intro- 
duction in  nulliparae  is  painful. 

Describe  the  the  bivalve  speculum. 

Brewer's  is  the  best  type  of  this  class.  It  consists  of  two 
blades,    trumpet-shaped,    which    expand    when    they    are    joined 

Fig.  7. 


Brewer's  Bivalve  Speculum. 

together  posteriorly,  and  are  held  open  by  a  screw-bolt.  The 
upper  blade  is  notched  at  its  expanded  extremity  to  prevent 
pressure  on  the  urethra  and  facilitate  the  passage  of  the  uterine 
sound. 

How  is  it  introduced? 

The  patient  lying  in  the  dorsal  position,  the  exact  location  of 
the  cervix  is  ascertained  by  digital  examination.  The  labia  are 
then  separated,  and  the  tip  of  the  closed  instrument  is  introduced — 


28 


DIAGNOSIS   OF   GYNECOLOGICAL   DISEASE. 


first  in  the  long  axis  of  the  vulva,  then  turned  transversely  and 
pushed  backward  toward  the  cervix.  Just  before  the  latter  is 
reached  the  blades  are  separated,  bringing  it  into  view. 

What  are  the  disadvantages  of  the  bivalve  speculum  ? 

It  conceals  the  anterior  vaginal  wall ;  it  distorts  the  cervix  ;  it 
cannot  be  used  for  operations  on  the  cervix  or  vagina. 

What  are  its  advantages? 

It  is  self-retaining,  thus  obviating  the  necessity  of  an  assistant. 
It  is  the  most  convenient  form  of  speculum  for  inspection  of  the 
cervix  and  local  applications. 

Describe  the  volsellum  and  bullet  forceps. 

The  volsellum  consists  of  two  pairs  of  hooks  on  the  ends  of  long 


Fig.  8. 


Volsellum  Forceps. 


There 


scissor  handles,  which  are  provided  with  a  spring  catch 
may  be  two  or  more  teeth  on  each  hook. 

The  bullet  forceps  are  the  same  as  the  above,  with  a  single  pair 
of  teeth.  These  are  of  great  use  in  drawing  down  the  cervix  for 
all  operations,  dilatations,  etc. ;  to  draw  down  and  steady  the  uterus 
in  rectal  examinations ;  and  to  steady  the  uterus  while  making 
intra-uterine  applications. 

Describe  the  Sims  tenaculum. 

This  consists  of  a  steel  hook,  bent  as  shown  in  the  figure,  and 


Fig.  9. 


Sims's  Tenaculum. 


fastened  into  a  slender  handle.     It  is  indispensable  in  all  operations 
upon  the  cervix  and  perineum. 


PHYSICAL   EXAMINATION. 

Fig.  10. 

QeoTIEMANNScCo. 


29 


uterine  Sound. 

SOUNDS. 

Describe  the  uterine  sound. 

The  best  form  of  this  instrument  is  the  one  devised  by  Simpson. 

Fig.  11. 


Method  of  Holding  the  Uterine  Sound. 


30 


DIAGNOSIS   OF   GYNECOLOGICAL    DISEASE. 


It  consists  of  a  graduated  flexible  metal  rod  having  a  knob  2J  inches 
from  the  end,  marking  the  depth  of  the  normal  uterus. 

Fig,  12. 


Method  of  Introducing  Uterine  Sound. 


What  are  the  contraindications  to  its  use? 

1st,  pregnancy ;  2d,  presence  of  menstruation  ;  3d,  any  peri- 
uterine inflammatory  condition,  or  tenderness  of  the  uterus  and 
appendages  ;  4th,  malignant  disease  of  the  uterus. 


PHYSICAL    EXAMINATION. 


31 


Describe  the  method  of  introduction. 

(1)  The  exact  curvature  and  position  of  the  uterus  are  ascer- 
tained by  bimanual  examination, 

(2)  The  vagina  is  thoroughly  cleansed. 

(3)  The  curvature  of  the  sound  is  made  to  conform  to  that  of 
the  uterus. 

(4)  The  index  finger  of  the  right  or  left  hand  is  introduced  into 
the  vagina  to  the  cervix,  and  the  sound,  passed  along  this  with  its 
concavity  backward,  is  guided  into  the  uterus  (Figs.  11  and  12). 
When  it  is  thoroughly  engaged  in  the  cervix  the  handle  is  made  to 
describe  a  semicircle  from  left  to  right,  bringing  the  concavity 
forward  (Fig.  13).     Now,  if  the  handle  is  depressed  toward  the 

Fig.  13. 


Diagrams  illustrating  Introduction  of  Uterine  Sound. 

perineum,  the  sound  will  readily  pass  into  the  fundus,  as  shown  in 
Fig.  14.  No  force  is  to  be  used,  and  the  handle  should  be  held 
lightly  between  the  thumb  and  forefinger. 

What  can  be  ascertained  by  the  use  of  the  uterine  sound  ? 

(1)  Potency  and  size  of  the  external  os  and  cervical  canal. 

(2)  Presence  of  intra-uterine  growths. 

(3)  Condition  of  the  endometrium. 

(4)  Sensitiveness  of  the  internal  os. 


32 


DIAGNOSIS   OF   GYNECOLOGICAL   DISEASE. 
Fig.  14. 


Uterine  Sound  Tntroduced. 

(.5)  Direction  of  the  cervical  canal  and  exact  position  of  the 
fundus. 

(6)  Relation  of  the  uterus  to  a  tumor. 

It  should  not  be  used  to  replace  a  malpositioned  uterus  or  to 
test  its  mobility. 

What  four  classes  of  instruments  are  employed  in  obtaining  a 
dilatation  of  the  cervix  ? 

(1)  Tents  ;  (2)  graduated  steel  and  hard-rubber  sounds  ;  (3)  steel 

branched  dilators  ;  (4)  dilatable  rubber  tubes. 

TENTS. 
What  are  the  three  varieties  of  tents  ? 

(1)  Sponge,  consisting  of  a  cone  of  compressed  sponge  rendered 
aseptic  and  covered  with  a  layer  of  grease.  It  is  provided  with  a 
tape  at  the  base  to  assist  in  removal. 

(2)  Laminaria  or  sea-tangle  tents,  made  from  the  Laminaria 
digit  at  a. 

(3)  Tupelo-wood,  made  from  the  Nyssa  aquatilis. 


PHYSICAL    EXAMINATION. 


33 


Describe  the  advantages  and  disadvantages  of  each. 

Sponge  tents  dilate  rapidly,  but  are  painful  and  likely  to  give 
rise  to  septicaemia  from  abrasions  of  the  mucous  membrane.     They 

Fig.  15. 


Introduction  of  a  Tent  (Sims). 

are  now  entirely  discarded.  Laminaria  tents  dilate  much  more 
slowly,  but  are  more  aseptic,  and  from  their  small  size  it  is  possible 
to  introduce  several  at  a  time  into  the  cervix.     Tupelo  tents  are 

3— Gyn. 


34  DIAGNOSIS    OF   GYNECOLOGICAL   DISEASE. 

tlie  best  of  call.  Their  expansibility  is  equal  to  the  sponge  tents, 
they  dilate  equably,  and  do  not  abrade  the  mucous  membrane. 
Sepsis  following  their  use  is  rare. 

"What  are  the  indications  for  the  use  of  tents  ? 

(1)  Uterine  hemorrhage  unexplainable  by  other  diagnostic  meas- 
ures. 

(2)  Locating  polypi  and  other  intra-uterine  growths. 

(3)  For  the  treatment  of  the  latter  and  for  the  removal  of  prod- 
ucts of  conception.     (This  is  a  dangerous  practice.) 

Describe  the  mode  of  introduction  of  tents. 

The  patient  is  placed  in  Sims  position.  Sims's  speculum  being 
introduced,  the  cervix  is  grasped  with  a  pair  of  bullet  or  volsellum 
forceps  and  drawn  down.  The  vagina  is  now  thoroughly  irrigated 
with  1  :  1000  bichloride-of-mercury  solution  and  the  cervical  canal 
swabbed  out.  Previously  the  exact  position  of  the  uterus  should 
have  been  ascertained  by  a  bimanual  examination,  and  the  curva- 
ture of  the  tent  made  to  conform  to  that  of  the  uterus.  The  tent 
is  then  grasped  with  a  pair  of  forceps  or  a  tent-passer  and  gently 
inserted  in  the  direction  of  the  uterine  canal  (Fig.  15).  A  pledget 
of  cotton  is  placed  against  the  cervix  and  the  patient  put  to  bed.  If 
pain  is  experienced,  a  morphine  suppository  may  be  administered. 
The  tent  should  not  be  left  in  more  than  from  six  to  twelve  hours, 
and  the  patient  should  be  kept  in  bed  a  day  longer.  Tents  should 
never  be  introduced  at  the  physician's  office. 

How  are  tents  now  regarded  as  a  means  of  diagnosis  and  treat- 
ment? 

They  have  been  almost  entirely  superseded  by  the  other  dila- 
tors, and,  according  to  Thomas,  should  be  discarded  entirely. 

STEEL  AND  HARD-RUBBER  SOUNDS. 

What  forms  of  graduated  steel  and  hard-rubber  sounds  are  in 
use?    Describe  them. 

(1)  Peaslee's;  (2)  Hank's;  (3)  Hegar's. 

The  Peaslee  dilators  (Fig.  IG)  resemble  male  sounds,  with  less 
curvature  and  a  bulb  2^  inches  from  the  end.  They  range  in  size 
from  a  15  to  20  French  male  sound.     The  Hanks  variety  have  oval 


PHYSICAL    EXAMINATION. 


35 


extremities  of  various  sizes,  capable  of  being  screwed  into  a  sigmoid 
handle.      The  Hegar  dilators  are  made  of  hard  rubber  with  a  de- 
tachable handle,  and  are  shaped  like  male 
sounds.     They  range  in  size  from  1  to  30.  Fig.  16. 


Describe  the  mode  of  introduction. 

The  patient  being  placed  in  Sims  posi- 
tion, a  Sims  speculum  is  introduced.  The 
vagina  is  thoroughly  irrigated  with  1  .: 
1000  bichloride-of-mercury  solution,  and 
the  cervical  canal  is  swabbed  out.  The 
anterior  lip  of  the  cervix  is  grasped  with 
volsellum  or  bullet  forceps,  and  drawn 
down.  Dilator  is  introduced  by  the  right 
hand  as  the  uterine  sound.  After  comple- 
tion of  dilatation  the  cervix  is  swabbed 
off  again  and  dusted  with  iodoform.  An 
iodoform  gauze  tampon  is  introduced,  and 
patient  put  to  bed  for  twelve  hours.  The 
dorsal  position  may  be  used. 


STEEL  BRANCHED  DILATORS. 

What  are  the  best  forms  of  the  steel 
branched  dilators? 

(1)  Groodell's  modification  of  Ellin- 
ger's  ;  (2)  Wylie's  modification  of  Sims's ; 
(3)  Palmer's. 

The  Goodell-Ellinger  is  probably  the 
best,  though  the  most  expensive  variety. 
It  is  constructed  in  two  sizes,  small 
slender  blades  and  large  powerful  ones. 
These  blades  separate  in  parallel  lines ; 
the  handles  are  provided  with  a  grad- 
uated  scale  having  a  screw  attachment. 


Peaslee's  Dilators. 


What  are  the  indications  for  the  use  of  dilators  ? 

(1)  Stenosis  of  the  cervix ;  (2)  constriction  at  the  internal  os 
from  anteflexions,  etc. ;  (3)  dilatation  of  the  cervix  for  diagnostic 
purposes  or  to  clean  out  the  uterine  cavity  after  abortions,  etc. 


36 


DIAGNOSIS   OF   GYNECOLOGICAL   DISEASE. 
Fig.  17.  Fig.  18. 


Goodell-Ellinger  Dilator. 


Wyle's  Modification  of 
Sims's  Dilator. 


How  are  the  branched  dilators  used? 

Tliese  are  best  introduced  in  the  lithotomy  or  Simon's  position, 
with  the  use  of  Simon's  speculum,  owing  to  the  advantages  of  excit- 


PHYSICAL    EXAMINATION.  37 

ing  counter-pressure  on  the  fundus.  The  vagina  is  thoroughly 
cleansed  with  1  :  1000  bichloride-of-mercury  solution.  The  cervix 
is  drawn  down  and  the  blades  introduced  up  to  the  shank.  Dila- 
tation is  made  gradually  by  means  of  the  screw,  so  as  to  enable  the 
muscular  fibres  of  the  cervix  to  yield  instead  of  rupturing.  The 
blades  may  be  separated  1  or  1^  inches.  Anaesthesia  should  always 
be  employed  for  complete  dilatation,  and  subsequent  treatment 
should  be  as  described  above  for  the  graduated  sounds. 

DILATABLE  TUBES. 

Describe  Barnes's  bags. 

These  are  small  rubber  bags  of  various  sizes,  provided  with 
a  rubber  tube.  On  one  side  of  the  bag  is  a  small  pocket  for  the 
end  of  the  bougie,  by  means  of  which  it  is  introduced  into  the 
cervix.  They  are  inserted  empty,  under  the  usual  antiseptic  pre- 
cautions, by  sight  with  a  speculum  or  by  touch.  They  are  then 
injected  slowly  with  air  or  warm  water  by  means  of  a  Davidson 
syringe. 

What  is  another  good  dilator  of  this  variety  ? 

The  Allen's  surgical  pump,  which  is  provided  with  india-rubber 
bags  similar  to  Barnes's,  and  expanded  with  air  or  water  by  means 
of  the  pump. 

Under  what  conditions  are  these  elastic  dilators  most  useful? 

(1)  In  a  pregnant  uterus  ;  (2)  intra-uterine  growths  with  pat- 
ulous OS. 

What  are  the  dangers  from  the  use  of  dilators  ? 

(1)  Lacerations  of  the  cervix ;  (2)  endometritis ;  (3)  salpingo- 
oophoritis  ;  (4)  sepsis. 

THE  CURETTE  AS  A  DIAGNOSTIC  AGENT 

What  are  the  two  forms  of  the  curette  ? 
The  sharp  and  the  dull. 

Which  of  these  is  used  in  diagnosis  ? 

The  dull  curette. 


38 


DFAGNOSIS   OF   GYNECOLOGICAL   DISEASE. 


Describe  it. 

It  consists  of  a  smooth  wire  loop  on  the  end  of  a  flexible  metal 


Fig.  19. 


^^ 


Thomas's  Dull  Curette. 

shaft  (Figs.  19  and  20),  and  is  made  in  three  sizes. 

Fig.  20. 


-—s^ 


-^o<i 


Sims's  Sharp  Curette :  o,  h,  showing  the  angles  at  which  it  may  be  bent. 


What  can  be  ascertained  by  its  use  ? 

(1)  The  character  of  the  contents  of  the  uterus  and  the  condi- 
tion of  the  endometrium  ;  (2)  the  cause  of  persistent  hemorrhage 
or  profuse  leucorrhoial  discharge.  It  scrapes  away  fungous  growths 
from  the  mucous  membrane,  and  removes  sloughing  masses  in 
malignant  disease  and  retained  secundines  after  abortions. 

How  is  it  employed? 

The  patient  is  placed  in  the  Sims  or  the  dorsal  position  (the  latter 
is  somewhat  ihe  better,  owing  to  the  advantage  of  exerting  counter- 
pressure  over  the  fundus).  A  Sims  or  Simon  speculum  is  intro- 
duced ;  the  cervix  is  grasped  by  its  anterior  lips  with  a  pair  of  ])ul- 
let  or  volsellum  forceps,  and  drawn  down.  The  cervix  and  vagina 
are  thoroughly  irrigated  and  swabbed  out  with  1  :  1000  bichloride-of- 
mercury  solution.  Dilatation  of  the  cervix  may  be  recjuired.  The 
direction  of  the  uterine  canal  having  been  previously  ascertained, 
the  curvature  of  the  curette  is  made  to  correspond.  It  is  then  in- 
troduced into  the  fundus  as  a  sound  with  the  right  hand,  the  left 
exerting  counter-pressure  over  the  fundus. 


PHYSICAL    EXAMINATION.  39 

The  anterior  wall  is  now  gently  scraped  down  and  the  curette 
removed,  bringing  with  it  any  uterine  fungositics  or  other  matter 
that  may  be  present.  It  should  be  rinsed  off  in  1 :  20  carbolic- 
acid  solution  before  being  reintroduced.  For  diagnostic  purposes 
this  will  suffice,  but  for  a  curative  effect  the  whole  lining  mem- 
brane must  be  scraped  down  until  it  becomes  smooth.  The  uterine 
cavity  is  then  thoroughly  irrigated  with  several  quarts  of  hot  1 :  100 
carbolic-acid  solution  by  means  of  a  double-current  catheter. 
When  the  hemorrhage  following  curetting  is  severe,  .^ij  or  ^iij  of 
tr.  iodi  may  be  added  to  the  hot  water.  The  vagina  is  then  dried, 
and  the  endometrium  painted  with  pure  carbolic  acid  or  iodized 
phenol : 

^.  Tr.  iod.,  gr.  xl ; 

Pure  carbolic  ac,         §j. 

An  iodoform  gauze  tampon  is  placed  over  the  cervix,  the  volsel- 
lum  and  speculum  are  removed,  and  the  patient  is  put  to  bed  for  at 
least  twenty-four  to  forty-eight  hours. 

Thorough  antiseptic  precautions  must  he  preserved  with  regard 
to  the  hands  and  instruments  throughout  a  curetting.  An  anaes- 
thetic should  be  admistered  when  practicable,  particularly  if  a 
sharp  curette  is  employed. 

What  other  forms  of  curettes  are  in  use  ? 

Martin's  (Fig.  21),  shaped  like  the  original  Recamier,  but  having 

Fig.  21. 
Martin's  Curette. 

a  dull  edge;  Simon's  spoon;  Sims's  and  Emmet's  sharp  curettes. 

What  are  contraindications  of  curetting  ? 

(1)  Suspicion  of  pregnancy  ;  (2)  evidences  of  recent  exudation 
about  the  uterus  ;   (3)  tenderness  in   the  fornices. 

What  are  the  dangers  of  curetting  ? 

(1)  Sepsis,  causing  inflammation  of  the  uterus,  appendages,  or 
peritoneum  ; 

(2)  Hemorrhage  ; 


40  EXTERNAL  ORGANS  OF  GENERATION. 

(3)  Curetting  with  coexisting  tubal  disease,  such  as  pyosalpinx, 
is  likely  to  cause  rupture. 

Describe  the  Bozeman-Fritsch  double-current  uterine  catheter. 

This  consists  of  two  tubes — one  enclosing  the  other  at  its  ex- 
tremity, where  it  is  curved  to  conform  to  the  uterine  cavity.  The 
outer  tube  is  'provided  with  a  fenestrum  on  either  side,  and  a  third 
opening  on  its   convex  aspect  about  three  inches  from   the  end. 

Fig.  22. 


Bozeman's  Intra-uterine  Back-flow  Tube. 


The  fluid  flows  in  by  the  small  tube  through  the  large  fenestrum, 
irrigating  the  uterine  cavity  ;  passes  back  through  the  large  fenes- 
trum, and  out  at  the  smaller  opening.  The  latter  lies  outside  of 
the  external  os. 


EXTERNAL  ORGANS  OF  GENERATION. 

ANATOMY. 

What  are  the  external  organs  of  generation? 

The  external  genitals,  also  called  vulva  and  pudendum^  include 
that  portion  of  the  genital  tract  which  is  visible  when  the  subject 
lies  upon  her  back  with  the  knees  drawn  up  and  abducted  and  the 
labia  majora  separated.     They  are  as  follows  : 

(1)  Mens  veneris  ;  (7)  Fourchette  ; 

(2)  Labia  majora  ;  (8)  Fossa  navicularis  ; 

(3)  Labia  minora  ;  (9)  Ostium  vagina?  and  vagina  ; 

(4)  Clitoris;  (10)  Bulbs  of  the  vagina  ; 

(5)  Vestibule;  (11)  Bartholin's  glands. 
(0)  Meatus  urinarius  J 


ANATOMY.  41 

The  hymen  is  sometimes  included  with  these,  but  really  separates 
the  external  genitals  from  the  vagina. 

The  hulhs  of  the  vagina  and  Bartholin  s  glands  are  structures 
regarded  as  common  to  the  vulva  and  vagina. 

The  mons  veneris  is  a  triangular  cushion  of  skin  and  adipose 
tissue  situated  in  front  of  the  symphysis  pubis,  and  it  is  covered 
after  puberty  with  a  thick  growth  of  coarse,  curly  hair,  usually  a 
few  shades  darker  than  the  hair  of  the  head.  It  is  bounded  above 
by  a  slight  groove  at  the  lower  limit  of  the  hypogastrium,  and 
below  becomes  continuous  with  the  labia  majora.  The  collection 
of  fat  is  supported  by  connective  tissue ;  the  skin  is  thick  and  con- 
tains numerous  subaceous  and  sweat  glands. 

The  labia  majora  are  two  thick  folds  of  integument,  enclosing 
fat,  connective  tissue,  and  blood-vessels,  which  extend  from  the 
lower  part  of  the  mons  veneris  (anterior  commissure)  downward 
and  backward,  uniting  with  each  other  in  the  posterior  commis- 
sure about  an  inch  in  front  of  the  anus.  Each  has  an  inner  and 
outer  surface,  the  latter  after  puberty  being  covered  with  hair,  and 
they  are  rich  in  sebaceous  and  sweat  glands.  The  inner  surface 
resembles  mucous  membrane,  but  contains  a  few  hair-follicles. 

The  elastic  tissue  of  each  labium  is  arranged  in  the  form  of  a 
sac,  with  its  neck  at  the  external  inguinal  ring,  and  here  are  some- 
times found  the  remains  of  the  canal  of  Nuck,  a  process  of  peri- 
toneum prolonged  upon  the  round  ligament.  When  this  is  pervious 
it  may  be  the  seat  of  a  labial  hernia.  The  terminal  fibres  of  the 
round  ligament  are  also  found  in  this  portion.  Normally,  in  the 
adult  the  labia  are  full  and  rounded  and  lie  in  contact  with  each 
other.  In  old  age  they  become  atrophied  and  separable,  allowing 
the  labia  minora  to  protrude. 

The  arterial  supply  is  derived  from  the  superficial  perineal  branch 
of  the  internal  pudic  and  superficial  pudic.  The  veins  begin  in  a 
rich  subcutaneous  plexus  and  unite  with  the  vaginal  bulbs.  They 
accompany  the  arteries.  The  nerves  are  derived  from  the  superficial 
perineal  branch  of  the  pudic  and  the  inferior  branch  of  the  small 
sciatic.     The  lymphatics  enter  the  inguinal  glands. 

Describe  the  labia  minora,  or  nymphae. 

These  are  two  muco-cutaneous  folds  situated  between  the  labia 
majora.  They  begin  anteriorly  below  the  anterior  commissure  in 
two  divisions.  The  upper  divisions,  or  roots,  unite  with  each  other 
above  the  clitoris,  forming  its  prepuce ;  the  lower  divisions  unite 


42  EXTERNAL    ORGANS    OF    GENP:RAT10N. 

below  to  form  its  fraenulum.  Each  labium  descends  along  the  base 
of  the  inner  surface  of  the  labia  majora,  with  which  it  blends  in 
the  middle  third.  In  the  virgin  they  are  completely  hidden  by 
the  labia  majora  and  are  of  a  pinkish-red  color.  In  appearance 
they  resemble  a  cock's  comb.  They  may  be  continued  into  the 
fourchette.  The  nerve-  and  blood-supply  is  the  same  as  for  the 
labia  majora.     They  contain  numerous  sebaceous  and  sweat  glands. 

Describe  the  clitoris. 

The  clitoris  is  a  curved  oblong  body,  the  analogue  of  the  male 
penis,  situated  below  the  anterior  commissure.  It  consists  of  the 
glans,  the  body,  and  two  crura.  The  glans  is  a  mass  of  erectile 
tissue  of  the  size  of  a  small  pea,  covered  by  mucous  membrane  rich 
in  nerve-supply.  It  is  concealed  by  the  prepuce,  and  is  only  seen 
when  the  labia  minora  are  widely  separated.  The  vessels  of  the  glans 
are  connected  with  those  of  the  pars  intermedia  of  the  bulb.  The 
body,  which  seldom  exceeds  an  inch  in  length,  curves  upward  and 
backward  to  the  anterior  edge  of  the  arch  of  the  pubis,  where  it 
divides  into  two  crura.  It  consists  of  spongy  erectile  tissue  enclosed 
in  a  dense  capsule.  The  two  crura  curve  downward  along  the  pubic 
rami,  to  the  anterior  and  inner  surface  of  which  they  are  firmly 
attached.  These  are  also  formed  of  spongy  tissue  enclosed  in  a 
capsule.  The  slender  erector  clitoridis  muscles  extend  along  their 
inner  sides.  The  arterial  supply  is  derived  from  the  two  terminal 
branches  of  the  internal  pudic.  The  dorsal  vein  returns  the  blood 
and  joins  the  vesical  plexus.  The  nerve-supply  is  very  abundant, 
derived  from  the  sympathetic  system  and  from  a  branch  of  the 
pudic  nerve.  The  lymphatics  form  a  plexus  around  the  clitoris, 
and  terminate  in  the  inguinal  glands. 

Describe  the  vestibule. 

This  is  a  triangular  area  with  its  apex  immediately  below  the 
clitoris,  its  base  formed  by  the  upper  margin  of  the  vaginal  orifice, 
and  its  sides  formed  by  the  bases  of  the  labia  minora.  It  is  covered 
by  mucous  membrane,  beneath  which  is  a  dense  plexus  of  veins, 
the  pars  intermedia.  It  contains  the  orifice  of  the  urethra  at  its 
base,  and  five  or  six  depressions  or  crypts  of  variable  size,  the 
glandulae  vestibulae  minores. 

Describe  the  bulbs  of  the  vagina  (bulbi  vestibuli). 

'J'Ik!  v<i(jiii((l  hitlhfi  are  two  oblong  leecli-slia|)ed  masses  of  veins 
situated  on  either  side  of  the  vestibule  and  extending  two-thirds 


ANATOMY.  43 

down  the  sides  of  the  vaginal  orifice.  They  measure,  when  dis- 
tended, about  1  inch.  Anteriorly  they  are  covered  partly  by  the 
bulbi  cavernosi  muscles  ;  internally  they  are  in  contact  with  the 
mucous  membrane  of  the  vagina  ;  and  posteriorly  they  rest  upon 
the  triangular  ligament.  Their  vessels  communicate  anteriorly 
with  each  other  through  those  of  the  pars  intermedia.  The  arterial 
supply  is  derived  from  the  internal  pudic.  The  nerves  come  from 
the  sympathetic. 

What  is  the  fourchette  ? 

This  is  a  fold  of  skin  formed  by  the  junction  of  the  labia  majora 
posteriorly.  It  is  the  posterior  commissure,  and  is  best  seen  when 
the  labia  are  widely  separated. 

What  is  the  fossa  navicularis? 

When  the  labia  are  artificially  separated  a  depression  exists 
anterior  to  the  fourchette.  Its  anterior  margin  is  formed  by  the 
ostium  vaginae  and  the  lower  edge  of  the  hymen. 

Describe  the  vulvo-vaginal   or  Bartholin   glands  (analogues   of 
Cowper's  glands  in  the  male). 

They  are  two  compound  racemose  glands  which  range  in  size 
from  a  bean  to  an  almond,  situated  on  either  side  of  the  vaginal 
orifice  just  below  the  ends  of  the  bulbs  of  the  vagina.  They  lie 
behind  the  anterior  layer  of  the  triangular  ligament,  beneath  the 
superficial  perineal  fascia,  and  in  front  of  the  transversus  perinei 
muscles.  Each  has  a  long  duct,  the  orifice  of  which  can  be  seen 
just  external  to  the  base  of  the  hymen  and  internal  to  the  labia 
minora  in  the  fossa  navicularis.  They  secrete  a  tenacious  mucus 
which  lubricates  the  parts  and  which  is  much  increased  by  coition. 

Describe  the  hymen. 

The  hymen  is  a  crescentic  fold  of  mucous  membrane,  containing 
connective  tissue,  blood-vessels,  and  nerves,  which  surrounds  the 
orifice  of  the  vagina.  It  is  said  to  be  an  infolding  of  the  entire 
vaginal  wall,  and  to  disappear  completely  at  parturition  (Budin) 
by  being  unfolded.  There  are  other  shapes  aside  from  the  crescen- 
tic— i  e.  annular,  with  a  central  opening  ;  perforated,  with  several 
small  holes  ;  cribriform,  or  it  ma}'^  be  fimbriated  at  its  edges. 

The  imperforate  hymen  is  a  pathological  condition.  Carunculae 
myrtiformes  were  supposed  to  be  remains  of  the  hymen  after  labor, 
but  are  really  tags  of  tissue  resulting  from  tears  and  sloughs  of 
the  mucous  membrane  during  childbirth. 


44         EXTERNAL  ORGANS  OF  GENERATION. 

Describe  the  vagina. 

The  vagina  is  a  musculo-membranous  canal  connecting  the  ute- 
rus with  the  vulva,  situated  between  the  bladder  and  urethra  in 
front  and  the  rectum  and  perineal  body  behind.  Its  walls  lie  nor- 
mally in  contact  with  each  other  antero-posteriorly.  The  anterior 
wall  measures  2  to  2^  inches,  the  posterior  3  to  3|,  owing  to  its 
higher  attachment  to  the  cervix.  Its  lumen  increases  from  below 
upward,  so  that  when  distended  it  takes  the  shape  of  an  inverted 
truncated  cone.  Above  it  completely  surrounds  the  cervix,  and 
below  it  is  attached  to  the  pubis  rami.  The  walls  are  composed 
of  three  coats  from  within  outward — mucous  membrane,  muscular 
and  connective  tissues.  The  mucous  membrane  is  thrown  into  folds 
or  rugae,  most  marked  below.  The  median  longitudinal  ridges  on 
the  anterior  and  posterior  walls  are  called  the  columns  of  the  vagina. 
Transverse  folds  extend  from  these.  The  epithelium  is  of  the  squa- 
mous variety.  The  muscular  coat  is  composed  of  two  sets  of  fibres 
— a  circular  and  a  longitudinal,  the  latter  being  external.  The  con- 
nective-tissue coat  serves  to  connect  the  vagina  with  the  adjacent 
organs  and  to  support  a  plexus  of  veins. 

Vasculai'  Sajiply. — The  arteries  are  derived  from  the  vaginal 
branches  of  the  anterior  division  of  the  internal  iliac,  from  the 
uterine  above  and  pudendal  below. — all  anastomosing  freely  with 
each  other.  The  veins  are  derived  from  two  plexuses,  one  internal 
beneath  the  mucous  membrane,  and  one  in  the  connective  tissue. 
These  communicate  with  the  pudendal  and  hemorrhoidal  plexus 
below  and  the  plexuses  of  the  broad  ligaments  above.  All  the 
veins  are  without  valves.  The  nerve-sup2)ly  is  derived  from  the 
inferior  hypogastric  plexus  of  the  sympathetic  and  fourth  sacral 
and  pudic  nerve.  Lymphatics  enter  the  inguinal  glands  below  and 
the  internal  iliac  above. 


What  are  the  relations  of  the  vagina  ? 

Anteriorly  the  vagina  is  in  contact  with  the  bladder  at  its  upper 
half,  and  is  intimately  connected  to  the  urethra  throughout  its 
lower  half.  Posteriorly  it  is  in  contact  with  the  rectum  at  its  mid- 
dle third,  being  separated  from  the  latter  above  by  the  pouch  of 
Douglas  and  below  by  the  perineal  body.  Laterally  the  levator 
ani  muscles  are  attached  to  it. 

The  anterior  fornix  is  I]  inches  from  the  vesico-uterine  perito- 
neal fold.     The  posterior  fornix  lies  in  contact  with  the  cul-de-sac 


DISEASES   OF   THE   VULVA.  45 

of  Douglas,  and  the  lateral  fornices  are  in  relation  to  the  bases  of 
the  broad  ligaments. 

DISEASES  OF  THE  VULVA. 

What  may  he  included  under  this  term? 

I.   Malformations ; 
II.  Tumors  and  new  growths  ; 
III.   Inflammations. 

MALFORMATIONS. 

Name  and  describe  malformations  of  the  vulva. 

(1)  Hypertrophy  of  the  labia  majora  and  minora  (the  latter  called 
the  Hottentot  apron).  The  causes  are  syphilis,  elephantiasis,  inflam- 
matory hypertrophy,  masturbation.  It  is  usually  seen  in  tropical 
climates.     The  treatment  is  surgical  when  required. 

(2)  Hypertrophy  of  the  clitoris.  Due  to  above  causes  ;  it  is 
most  frequently  seen  in  prostitutes.     The  treatment  is  surgical. 

(3)  Atrophy  or  absence  of  the  organs  of  the  vulva  is  either  con- 
genital or  senile.     There  is  no  treatment. 

(4)  Hypospadias  is  absence  of  the  posterior  urethral  wall. 

(5)  In  epispadias  the  anterior  wall  of  the  urethra  and  usually 
of  the  bladder  is  defective. 

(6)  Hermaphroditism. 

TUMORS  AND  NEW  GRO'WTHS. 

What  tumors  and  neoplasms  may  be  met  with  in  the  vulvar 
region  ? 

Condylomata  acuminata  (gonorrhceal,  warty)  ; 

Condylomata  lata  (syphilitic)  ; 

Simple  papillomata ; 

Vulvar  cysts  (rare)  ; 

Vulvar  hernia  ; 

Vulvar  phlebectasia  or  varicocele  ; 

Vulvar  hasmatocele  and  pudendal  hemorrhage  ; 

Labial  abscess ; 

(Edema  labiorum  ; 

Abscess  and  cysts  of  vulvo-vaginal  glands ; 

Hydrocele  of  the  round  ligament  • 


46  DISEASES   OF   THE   VULVA. 

Elephantiasis  vulvae  ; 

Fibroma, 

Lipoma, 

Carcinoma, 

Sarcoma, 

Lupus,  y  rare. 

Myxoma, 

Osteoma, 

Enchondroma, 

Neuroma, 

Describe  condylomata  acuminata. 

These  are  also  known  as  pointed  condylomata  and  gonorrhoea! 
warts.  They  are  warty  excrescences  found  on  the  inner  surfaces 
of  the  labia  majora  and  minora  and  on  the  posterior  commissure, 
due  to  gonorrhoeal  or  other  irritating  discharges.  They  are  always 
multiple,  of  a  grayish  color,  and  are  divided  on  the  summit  with 
pointed  lobules.  The  treatment  is  removal  with  knife  or  scissors 
and  cauterization  with  nitrate  of  silver. 

Describe  the  condylomata  lata. 

These  are  flat,  broad  excrescences  found  mostly  on  the  inner 
sides  of  the  labia  majora  and  around  the  anus,  and  are  usually 
covered  by  a  grayish  secretion.  The  treatment  is  antisyphilitic, 
touching  with  nitric  acid  and  dusting  with  calomel  powder. 

Describe  simple  papilloma  or  wart. 

This  is  rare  on  the  vulva. 

Treatm,ent. — Removal  with  nitric  acid  or  the  knife. 

Describe  vulvar  cysts. 

These  rare  affections  are  due  to  occlusion  of  one  or  more  of  the 
glands  of  the  vulva.  They  are  usually  small  and  cause  no  symp- 
toms. 

Treatment  is  excision. 

Describe  vulvar  hernia. 

This  is  a  rare  condition,  "predisposed  to"  by  a  pervious  "canal 
of  Nuck."  It  is  caused  by  severe  exertion,  strains,  etc.  Symp- 
toms.— Correspond  to  those  in  the  male.  Swelling  of  the  labia 
majora,  impulse  on  coughing,  tympanitic  percussion.  It  may  con- 
sist of  gut,  omentum,  bladder,  ovary,  or  whole  uterus.  Differ- 
entiation from  vulvar  hn3matocele,  hydrocele  of  the  cord,  phlegmon- 


TUMORS  AKD   NEW  GROWTHS.  47 

ous  vulvitis,  cysts,  and  abscess  of  Bartholin's  glands.  Treatment. — 
Reduction  by  taxis  when  possible,  and  application  of  a  truss ; 
otherwise  operative. 

Describe  vulvar  varicocele. 

This  is  commonly  seen  in  pregnancy,  and  consists  of  a  dilatation 
of  the  vulvar  veins.  The  dilatation  may  be  permanent  and  give 
rise  to  great  swelling. 

Causes. — Pregnancy,  tumors,  obstinate  constipation  with  strain- 
ing at  stool.  Symptoms. — Discomfort  from  the  swelling.  The 
latter  is  irregular  in  outline,  soft  and  compressible,  more  prominent 
when  the  patient  is  standing.  Danger. — Rupture  of  the  veins. 
Treatment. — Very  little  can  be  done.  Pressure  with  a  T-bandage 
may  be  beneficial.     Keep  the  bowels  regulated. 

Describe  vulvar  hsematocele. 

This  is  a  tumor  formed  by  effused  coagulated  blood  in  the  tissues 
of  the  labium  or  areolar  tissue  around  the  vagina,  due  to  rupture  of 
the  bulbs  of  the  vestibule.  Causes. — Predisposed  by  pregnancy, 
tumors,  varicocele,  and  labor.  Exciting  causes  are  muscular  exer- 
tions, blows  on  the  labium,  and  punctures.  St/mjJtoms. — Sense 
of  discomfort,  pain,  and  throbbing.  If  the  effusion  reaches  the 
urethra,  there  will  be  obstruction  to  urination.  It  is  first  soft, 
then  hard. 

Prognosis. — If  small,  there  will  be  spontaneous  absorption  ;  if 
large,  it  may  result  in  hemorrhage  or  suppuration,  especially  when 
the  hsematocele  occurs  in  pregnancy. 

Differentiation  from  labial  abscess,  phlegmonous  vulvitis,  puden- 
dal hernia,  suppurative  bartholinitis,  oedema  labiorum.  Treatment. — 
During  the  effusion  cold,  and  pressure  later  ;  if  small,  lead-and-opium 
wash  applied  locally.  If  too  large  to  absorb  or  if  it  obstructs 
labor,  open  and  evacuate  it.  If  suppuration  takes  place,  evacuate 
and  pack  with  iodoform  gauze  or  wash  with  1  :  1000  bichloride-of- 
mercury  solution,  and  apply  acetate-of-aluminum  dressing. 

Describe  vulvar  hemorrhage. 

It  is  due  to  the  above  predisposing  and  exciting  causes.  Treat- 
ment.— If  due  to  ruptured  vulvar  hematocele,  open,  turn  out  clots, 
and  pack  tightly  ;  apply  T-bandage.  If  due  to  rupture  of  a  small 
vessel,  ligate. 

What  is  oedema  labiorum? 

Swelling  of  the  labia  is  most  common  in  pregnancy.     It  is  also 


48  DISEASES   OF   THE   VULVA. 

due  to  cardiac,  renal,  and  liver  diseases,  cancer  of  uterus,  wasting 
diseases,  fibroids,  and  ovarian  tumors.  Treatment  directed  to  cause  ; 
puncture  if  necessary,  recumbent  position,  T-bandage. 

Describe  abscess  of  labium.     (See  Phlegmonous  Vulvitis.) 
Describe  cysts  and  abscess  of  vulvo-vaginal  or  Bartholin's  glands. 

Cysts  are  due  to  occlusion  of  the  duct  from  inflammation,  either 
of  simple  or  gonorrhoea!  origin.  There  may  be  distension  of  the 
duct  alone,  forming  an  oblong  swelling,  or  of  the  gland  itself.  The 
causes  of  abscesses  are  much  the  same  as  vulvitis,  which  they 
frequently  complicate.  Gonorrha3a  is  the  most  common  cause. 
Symptoms. — Pain  on  pressure,  heat,  and  pruritus.  The  mouth  of 
the  duct  is  reddened,  and  remains  always  of  a  deeper  hue  than  the 
surrounding  inflamed  mucous  membrane.  The  swelling  may  reach 
the  size  of  a  hen's  egg.     It  is  first  hard,  then  fluctuating. 

Differentiation  from  cysts,  phlegmonous  vulvitis,  labial  abscess, 
and  vulvar  hernia. 

Abscess :  Cysts : 

Signs  of  inflammation.  No  signs  of  inflammation. 

Tenderness  on  pressure.  Movable  round  mass,  not  tender 

to  pressure. 

Abscess  :  Phlegmonous  Inflammation  : 

Circumscribed.  Non-circumscribed. 

Cyst  or  Abscess  :  Hernia 

History. 

No  impulse  on  coughing.  Impulse  on  coughing. 

Not  reducible.  Reducible. 

Dull  percussion.  Tympanitic  percussion. 

Abscess  shows  signs  of  inflam-  No  signs  of  inflammation  unless 
mation.  strangulated. 

Treatment  of  Vulvo-vaginal  Cyst. — Cut  down,  remove  an  ellipti- 
cal portion  of  cyst-wall,  pack  with  iodoform  gauze,  and  allow  to 
heal  by  granulation  ;  or,  cut  down  carefully  to  the  cyst-wall  and 
dissect  out  the  whole  sac ;  then  bring  the  edges  of  the  wound 
together  with  catgut  and  dress  antiseptically. 

Treatment  of  Vulvo-vaginal  Abscess. — Apply  soothing  lotions  until 
pus  is  detected  ;  then  make  a  long  incision  from  top  to  bottom  of  the 
abscess  on  the  inner  side  of  the  labium.     Curette  out  the  cavity 


INFLAMMATIONS.  49 

thoroughly  with  a  sharp  curette.  Irrigate  with  1  :  1000  bichloride- 
of-mercury  solution,  pack  with  iodoform  gauze,  and  dress  antisep- 
tically. 

Describe  hydrocele  of  the  cord. 

This  is  very  rare,  and  is  caused  by  fluid  collecting  in  the  process 
of  peritoneum  surrounding  the  round  ligament  when  pervious 
(canal  of  Nuck.)  It  appears  gradually,  is  painless,  and  sometimes 
communicates  with  the  peritoneal  cavity.  It  is  fluctuating  and 
translucent,  and  is  to  be  differentiated  from  hernia  and  abscess. 

Treatment  is  by  aspiration  or  injections  of  iodine. 

Describe  elephantiasis  vulvse. 

This  usually  involves  the  labia  majora  and  minora,  and  consists 
of  a  connective-tissue  hyperplasia.  The  growth  often  attains  an 
excessive  size. 

Treatment  is  surgical. 

INFLAMMATIONS. 

What  six  forms  of  vulvitis  are  described  ? 

(1)  Simple  catarrhal  vulvitis,  acute  and  chronic ;  (2)  gonor- 
rhoeal  vulvitis ;  (3)  follicular  vulvitis  ;  (4)  diphtheritic  vulvitis ; 
(5)  phlegmonous  vulvitis  ;  (6)  gangrenous  vulvitis. 

Describe  simple  acute  catarrhal  vulvitis. 

The  causes  are  (1)  irritating  discharges  from  the  vagina  and 
cervix;  (2)  injury,  or  friction  from  exercise;  (3)  uncleanliness ; 
(4)  excessive  coitus ;  (5)  parasites,  pediculi  and  ascarides ;  (6)  dia- 
betes ;  (7)  pregnancy  ;  (8)  foreign  bodies  ;  (9)  acute  exanthemata  ; 
(10)  strumous  diathesis. 

The  si/mptoms  may  be  general  malaise  and  mild  fever.  The  local 
signs  are  heat,  redness,  swelling,  pruritus  ;  the  mucous  membrane 
is  at  first  tense  and  shiny,  later  it  becomes  covered  with  a  glairy 
excoriating  secretion.  The  inflammation  may  extend  to  the  urethra 
and  around  the  anus  and  nates. 

Treatment. — Remove  the  cause.  If  parasitic,  use  unguentum 
hydrarg. ;  infusion  of  quassia,  ^ij-Oj,  for  ascarides.  If  due  to  dis- 
charges from  the  vagina  and  cervix,  remove  these  by  hot  vaginal 
douches  containing  a  little  alum  and  zinc  sulphate.  Always  ex- 
amine for  sugar  in  the  urine,  and  if  it  is  found  treat  general  system 
with  opium  or  codeine,  etc.,  and  apply  a  solution  of  sodium  hypo- 
sulphite, ^ss-Oj,  to  prevent  fermentation  of  the  saccharine  urine 
4— Gyn. 


50  DISEASES   OF   THE   VULVA. 

on  the  vulva.  When  the  inflammation  is  very  acute  apply  lead- 
and-opium  wash  and  enjoin  rest  in  bed  and  hot  sitz-baths.  Later 
in  the  disease  applications  of  nitrate  of  silver,  gr.  xx-^j,  can  be 
made  every  two  days. 

Describe  simple  chronic  catarrhal  vulvitis. 

This  is  the  most  common  form  in  children. 

Causes. — Strumous  diathesis,  ascarides,  continuation  from  acute 
vulvitis. 

Symptoms. — Pruritus,  burning  micturition,  discomfort  in  walk- 
ing, discharge  from  vulva. 

Treatment. — Tone  up  the  general  system  by  tonics  ;  locally,  lead- 
and-opium  wash  can  be  applied  first,  followed  later  by  nitrate  of 
silver,  gr.  xx-^j,  and  boric-acid  powder. 

Describe  gonorrhceal  or  purulent  vulvitis. 

The  cause  is  specific  infection,  due  to  the  gonococcus  of  Neisser. 

The  symptoms  are  its  sudden  onset,  pain,  heat,  redness,  and 
swelling,  followed  rapidly  by  a  profuse  purulent,  offensive  excori- 
ating discharge.  It  is  frequently  complicated  by  urethritis,  barthol- 
initis, and  vaginitis.  Labial  abscess  is  a  common  complication. 
The  pus  infects  any  mucous  membranne  with  which  it  is  brought 
in  contact.     The  orifices  of  Bartholin's  elands  are  reddened. 


&' 


Differentiation . — 

Gonorrhoeal  Vulvitis  :  Simple  Vulvitis  : 

More  severe.  Less  severe  onset. 

More  fever,  pain,  and  oedema.  Less  fever,  pain,  and  oedema. 

Urethra    and    vagina    often    in-  Urethra  and  vagina  not  compli- 

volved.  cated. 

Gonococci.  No  gonococci  in  discharges. 
Gonorrhoeal  warts. 
Gonorrhoeal  rheumatism. 

Bartholin  s  glands  and  ducts  in-  Bartholin's  glands  and  ducts  not 

flamed.  usually  affected. 

Treatment. — Hot  sitz-baths  ;  rest  in  bed  ;  bowels  moved.  Local : 
Irrigation  with  bichloride  ;  paint  with  nitrate  of  silver,  gr.  xx-.|_j  ; 
powder  with  bismuth,  calomel,  or  iodoform,  and  separate  labia  with 
a  little  lint. 


INFLAMMATIONS.  51 

Describe  follicular  vulvitis. 

It  occurs  only  in  adults. 

The  causes  are  unclean! iness,  pregnancy,  vaginitis,  eruptive  dis- 
eases, excessive  venery. 

The  symptoms  are  increased  secretion,  burning  and  itching,  heat, 
and  soreness  between  the  labia.  The  mucous  membrane  is  red, 
elevated  in  patches  ;  lips  swollen  ;  villi  which  bleed  easily ;  or  there 
may  be  little  red  prominences  which  break  down,  discharge,  and 
leave  little  ulcerated  points. 

Treatment. — Cleanliness,  lead-and-opium  wash,  nitrate  of  silver, 
gr.  X— ^j;  bismuth. 

Describe  diphtheritic  vulvitis. 

This  is  really  diphtheria  of  the  vulva,  and  a  complication  of  the 
general  disease.  The  patches  of  false  membrane  are  like  those 
found  in  the  throat,  and  resemble  wash-leather. 

Treatment. — General :  for  diphtheria.     Local :  antiseptic. 

Describe  phlegmonous  vulvitis. 

Causes. — Traumatism,  chancroidal  ulcers,  irritating  discharges, 
furuncles,  acute  exanthemata. 

Symptoms. — Heat,  pain,  swelling,  redness,  induration,  suppura- 
tion. 

Differentiation. — 

Phlegmonous  Vulvitis  :  Pudendal  Hernia  : 

Signs  of  inflammation.  No  inflammation,  unless  strangu- 

lated. 
Dulness  on  percussion.  Tympanitic. 

No  impulse  on  coughing.  Impulse  on  coughing. 

Not  reducible.  Keducible. 

History.  History. 

Phlegmonous  Vulvitis:  Vidvar  Hsematocele: 

More  gradual  onset.  Sudden  onset. 

First  hard,  then  soft.  First  soft,  then  hard. 

Not  frequent  during  pregnancy  More  frequent  during  pregnancy 

and  parturition.  and  parturition. 

Not  preceded,  as  a  rule,  by  vari-  Preceded  by  varicose  veins. 

cose  veins. 


52  DISEASES   OF   THE   VULVA. 

Phlegmonous  Vulvitis  :  Hydrocele  of  the  Cord : 

Signs  of  inflammation.  No  inflammation. 

Opaque.  Translucent. 

May  communicate  with  abdom- 
inal cavity. 

Phlegmonous  Vulvitis  :  Abscess    of  Bartholin  s    Glands  : 

Not  circumscribed.  Circumscribed. 

Describe  gangrenous  vulvitis. 

Usually  indicates  a  low  vitality  of  the  system.  It  is  sometimes 
a  complication  of  pregnancy,  puerperal  septicaemia,  severe  cases  of 
scarlet  fever,  measles,  and  continued  fevers. 

Symjjfoms. — Severe  constitutional  disturbance,  labia  dark-colored 
and  swollen.  A  patch  of  purplish  hue  becomes  indurated  at  edges 
and  ulcerates.  The  gangrenous  process  spreads,  and  discharges 
a  foetid,  ichorous  fluid. 

Treatment. — Tonics.  Local :  Antiseptics  and  cauterizing  with 
nitrate  of  silver  or  actual  cautery. 

What    is  the  most  common  of  the  eruptive  diseases  that   may 
appear  on  the  vulva? 

Eczema. 

Give  the  etiology,  symptoms,  and  treatment  of  eczema  vulvae. 

It  is  most  common  near  the  climacteric  and  in  fleshy  women. 
By  far  the  most  common  ca.use  is  diabetes,  from  the  fermentation 
of  the  saccharine  urine.  Other  causes  are  irritating  discharges, 
scratching  from  pruritus  vulva?.  There  is  a  predisposition  if  a 
a  gouty  or  rheumatic  diathesis  exists. 

^iymj)toms  and  Appearances. — It  usually  begins  on  the  inner  sur- 
faces of  the  labia  in  the  shape  of  small  vesicles  and  abrasions. 
These  extend  to  the  other  parts  of  the  vulva.  Intense  pruritus  is 
a  prominent  symptom.  Later  there  are  redness,  heat,  and  numer- 
ous little  vesicles  rupture  and  discharge  a  serous,  sticky  fluid. 
Finally,  the  labia  become  dry,  hard,  fissured,  and  swollen,  covered 
with  crusts  and  scales  ;  the  mucous  membrane  is  white  and  sodden, 
especially  at  the  anterior  commissure. 

Treatment. — If  due  to  diabetes,  frequent  applications  of  a  solu- 
tion of  hyposulphite  of  soda,  sss-Oj,  will  relieve  the  pruritus 
and  allay  the  inflammation.  Give  codeine,  gr.  ^,  t.i.  d.,  internally. 
If  due  to  other  causes,  lead-and-opium  wash  in  the  acute  stage  is 


CUTANEOUS  AND  NERVOUS  AFFECTIONS  OF  THE  VULVA.     53 

good.     In  the  chronic  form  an  ointment  of  8  per  cent,  ichthyol  in 
lanoline  is  highly  recommended,  or  5  per  cent,  creolin  emulsion. 

What  ulcerations  may  be  met  with  in  the  vulva? 

Hard  and  soft  chancres,  non-specific  ulcerations,  sometimes  in 
childbed  and  prostitutes,  forming  small  sensitive  sores  around  the 
entrance  of  the  vagina  and  hymen. 

CUTANEOUS   AFFECTIONS   OF   THE   VULVA. 
What  forms  of  skin  diseases  may  affect  the  vulva  ? 

Alopecia,  herpes  labialis,  prurigo,  acne,  simple  erythema,  ery- 
sipelas, pityriasis  versicolor,  scabies,  pediculus  pubis. 

What  two  forms  of  parasites  may  be  found  on  the  vulva  ? 

Scabies  (rare),  pediculi  pubis  (common). 
Give  etiology,  symptoms,  and  treatment  of  scabies. 

Due  to  the  presence  of  the  acarus  scabei.  This  is  rarely  found 
on  the  vulva,  but  may  complicate  the  general  infection. 

Symiotoms. — Intense  pruritus ;  the  presence  of  the  burrows  on 
the  vulva,  with  others  on  the  hand  and  between  the  fingers,  will 
lead  to  the  diagnosis. 

Treatment. — Sulphur  ointment,  gr.  xx-^j,  or  combined  with  bal- 
sam of  Peru. 

Give  the  etiology,  symptoms,  and  treatment  of  pediculi  pubis. 

This  is  due  to  the  presence  of  the  pediculi  pubis,  or  crab-louse, 
under  the  skin.     It  is  conveyed  by  direct  infection  nearly  always. 

Symptoms. — Intense  itching ;  presence  of  small  red  spots,  in 
which  the  parasite  can  be  seen  with  its  ova  and  excrement.  The 
eruption  resembles  eczema. 

Treatment. — It  is  well  to  begin  the  treatment  of  most  eruptions 
on  the  vulva  with  a  5  per  cent,  solution  of  carbolic  acid  as  a  lotion. 
Mercurial  ointment  and  the  tincture  of  delphinium  will  destroy  the 
parasites. 

NERVOUS  AFFECTION  OF   THE   VULVA. 

Describe  pruritus  vulvae. 

Pruritus  vulvae  is  an  intense  itching  and  burning  of  the  vulva. 
It  is  a  common  symptom  of  a  large  number  of  the  eruptive  and 
inflammatory  diseases  just  considered,  but  the  symptom  may  exist 
without  any  apparent  anatomical  lesion. 


54  DISEASES   OF   THE   VULVA. 

What  are  the  causes? 

(1)  Irritating  discharges  :  ((()  Urine  ;  (6)  vaginal ;  (c)  uterine  ; 
(d)  urethral ;  (e)  from  the  vulvo-vaginal  glands  and  from  Skene's 
ducts. 

(2)  Diabetic  urine  ; 

(3)  Eruptions ; 

(4)  Masturbation  ; 

(5)  Uncleanliness ; 

(6)  Neurotic  influences,  met  with  most  commonly  during  preg- 
nancy ; 

(7)  Parasites ; 

(8)  Ascarides ; 

(9)  Vegetable  parasites : 

(10)  Anything  giving  rise  to  a  congestion  may  cause  pruritus : 

(a)  Pregnancy ; 

(b)  Tumors  ; 

(c)  Menopause  ; 

(c?)  Carcinoma  uteri. 

Symptoms. — Intense  itching  on  the  surface  of  the  vulva,  at  first 
localized  over  a  limited  area,  the  anterior  commissure,  inner  sides 
of  labia  majora  and  nymphae,  later  extending  to  all  the  external 
organs.  The  sensation  is  not  generally  constant,  except  after  the 
menopause,  being  brought  on  or  increased  in  severity  by  exercise 
or  coitus.  It  may  only  appear  at  night  or  early  in  the  morning, 
and  is  usually  much  increased  by  the  warmth  of  bed-clothes.  In 
young  women  the  symptom  is  generally  intermittent ;  after  the 
menopause  it  becomes  more  intractable  and  constant. 

Treatment. — Directed  to  the  cause.  If  of  parasitic  origin,  re- 
moval. If  diabetic  urine,  hyposulphite  of  soda  locally,  5ss-0j,  and 
codeine  or  salicylate  of  soda  internally.  If  due  to  irritating  dis- 
charges, these  must  be  treated.  A  plug  of  dry  borated  cotton 
pushed  into  the  vagina,  to  prevent  the  contact  of  a  discharge,  will 
often  afford  great  relief.  Build  up  the  system  ;  regulate  diet  if 
there  is  a  gouty  diathesis  ;  frequent  hot  sitz-baths  ;  2-3  per  cent, 
carbolic  solution  applied  locally  ;  4  per  cent,  cocaine  solution  ;  nitrate 
of  silver  ;  boric-acid  dusting  powder. 


B.   Acidi  acetici.  f^j  ; 

Glyccrini,      '  f^'ij._M. 

Sig.  Apply  locally. 


NERVOUS    AFFECTION   OF   THE   VULVA.  55 

What  is  hypersesthesia  vulvae? 

(This  condition  was  first  described  by  Thomas).  It  consists  of 
an  excessive  sensibility  of  the  nerves  supplying  some  portions  of 
the  vulva — labia  majora,  minora,  vestibule,  or  urethra.  It  is  not 
very  frequent. 

Give  its  etiology,  symptoms,  and  treatment. 

It  occurs  most  commonly  about  the  menopause,  and  is  predis- 
posed by  an  hysterical  state.  Chronic  vulvitis  and  irritable  urethral 
caruncles  may  be  exciting  causes.     Often  no  cause  can  be  found. 

S^mjjtoms. — Dyspareunia,  or  painful  intercourse,  is  usually  the 
most  prominent  symptom,  sometimes  pain  in  walking  or  on  bathing 
the  parts.  The  general  health  may  suffer,  and  a  state  of  melan- 
cholia may  be  developed. 

Treatment. — Change  of  scene  unsatisfactory,  better  separation 
from  husband,  tonics,  bromides.  Locally :  Carbolic  acid,  3  per 
cent. ;  cocaine,  cyanide  of  potash  (with  caution). 

Define  vaginismus. 

Vaginismus  is  an  intense  hypersesthesia  of  the  vulvar  outlet 
and  spasm  of  the  constrictor  vaginae  muscle,  brought  about  by 
attempted  coitus.     The  spasm  may  become  general. 

What  are  its  causes  ? 

It  may  be  due  to  some  pathological  lesion  of  the  vulvar  outlet 
or  hymen,  to  disease  of  the  uterus,  ovaries,  or  tubes,  or  it  may  be 
purely  nervous,  or  it  may  be  caused  by  a  rigid  hymen,  small  vul- 
var orifice,  or  by  the  vulva  being  placed  too  high  under  the  sym- 
physis. Sometimes  tender  spots  are  found  on  the  hymen,  due  to 
inflammation  of  the  papillae.  In  nervous  women  inability  of  the 
male  to  perform  the  sexual  act  is  sometimes  the  cause. 

What  are  its  symptoms? 

Excessive  pain  and  muscular  spasm  around  the  vulva,  induced 
by  attempted  coition  or  any  endeavor  to  pass  the  vulvar  opening. 

What  is  the  treatment? 

Excising  the  hymen  and  uniting  the  edges  to  prevent  granula- 
tion, afterward  inserting  a  glass  plug ;  forcible  dilatation  under 
anaesthetics  and  introduction  of  glass  plug ;  local  applications  of 
cocaine,  nitrate  of  silver,  tr.  iodine,  hot  douches,  and  sitz-baths.  If 
due  to  diseases  of  uterus,  rectum,  etc.,  treat  these. 


56  DISEASES   OF   THE    VULVA. 

IRRITABLE  URETHRAL  CARUNCLE. 

Give  its  pathology,  etiology,  symptoms,  and  treatment. 

Pathology. — Urethral  caruncles  appear  as  briglit-red  vascular 
tumors  projecting  from  the  meatus  or  extending  up  into  the  urethra. 
They  are  exceedingly  painful  to  the  touch  and  bleed  easily.  They 
consist  of  hypertrophied  papillae  and  areolar  tissues.  They  are 
very  richly  supplied  with  blood-vessels  and  nerves.  They  may  be 
single  or  multiple,  sessile  or  pedunculated. 

Etiology. — The  cauae  is  unknown.  They  occur  in  young  and  old 
alike  ;  often  follow  acute  urethritis  or  chronic  gonorrhoeal  urethritis  ; 
may  be  due  to  a  pathological  state  of  the  urine. 

Symptoms. — Severe  pain  on  urination  may  be  accompanied  by 
spasm  of  muscles  of  vulva  and  sphincter  ani ;  pain  on  coition  and 
walking ;  the  constitution  may  run  down.  Excessively  painful  to 
the  touch. 

Differentiation  from  prolapse  of  urethral  mucous  membrane, 
polypi,  and  venereal  warts. 

Treatment. — Ligate  and  remove  with  knife.  Prognosis  is  good 
if  single,  worse  if  multiple.  Cauterizing  may  be  employed-,  pre- 
ceded by  dilatation  of  the  meatus  under  anaesthesia. 

COCCYGODYNIA   OR  COCCYODYNIA. 
Describe  coccygodynia  or  coccyodynia. 

Coccygodynia  is  a  painful  affection  of  the  muscles,  tendons,  and 
nerves  of  the  coccyx,  due  most  frequently  to  childbirth,  but  may 
be  caused  by  traumatism,  with  fracture  and  fixation  of  the  coccyx 
in  an  abnormal  position,  or  dislocation.  It  may  be  the  expression 
of  disease  in  other  organs,  as  the  uterus,  ovaries,  and  rectum.  It 
may  be  rheumatic  or  brought  on  by  exposure  to  cold,  or  it  may  be 
hysterical.     There  may  or  may  not  be  disease  of  the  bone. 

Symptoms. — Pain  at  the  end  of  the  spine,  inability  to  rise  from 
sitting  posture,  due  to  the  stretching  of  the  fascia  ;  painful  defeca- 
tion ;  painful  coitus  ;  pain  on  walking  or  sitting  down. 

Diagnosis. — This  is  made  by  placing  a  finger  in  the  rectum  and 
moving  the  bone,  or  by  pressure  on  the  coccyx  from  the  outside. 

Treatment. — If  hysterical  or  due  to  disease  of  other  organs,  they 
must  be  treated.  If  rheumatic  or  gouty,  these  conditions  must  be 
attended  to.  Counter-irritation  by  actual  cautery  or  blisters  ;  elec- 
tricity.    If  these  fail,  operative  measures :   (1)  Separation  of  the 


DISEASES   OF   THE    VAGINA.  57 

coccyx  from  tendinous  and  muscular  attachments  :  (2)  total  extir- 
pation. 

PROLAPSUS   URETHRJE. 

Describe  prolapsus  urethras. 

This  is  a  prolapse  of  the  urethral  mucous  membrane,  witli  pro- 
liferation of  the  underlying  connective  tissue  ;  slight,  is  common  ; 
considerable,  is  rare.  It  is  met  with  in  old,  feeble  women  and 
young  girls  before  puberty.  It  appears  as  a  protrusion  entirely 
or  partially  encircling  the  meatus.  After  existing  some  time  it 
becomes  inflamed  and  red,  bleeding  readily. 

For  what  can  this  be  mistaken? 

Urethral  caruncle,  polypi,  carcinoma. 

How  would  you  differentiate  it  from  irritable  urethral  caruncle  ? 

It  entirely  encircles  the  meatus  as  a  rule,  while  caruncle  does 
not.     It  is  less  painful ;  may  be  reducible. 

Symptoms. — Painful  and  frequent  micturition.  It  may  give  rise 
to  urethritis  and  cystitis.  Pruritus  may  be  set  up  by  the  dis- 
charge. 

Treatment. — If  slight,  astringents ;  if  severe,  angesthetize  the 
patient ;  draw  down  the  prolapsed  mucous  membrane  with  toothed 
forceps  and  remove  with  scissors.  Then  sew  the  edges  of  the 
mucous  membrane  together ;  afterward  catheterize  the  bladder  and 
do  Emmet's  buttonhole  operation.  Another  method  is  to  draw 
down  the  mucous  membrane,  ligate,  and  remove  with  a  knife  or 
cautery. 

DISEASES  OF  THE  VAGINA. 

What  diseases  may  be  met  with  in  the  vagina? 

Inflammations,  cysts,  ulcerations,  malformations,  displacements. 

INFLAMMATIONS   OF   THE  VAGINA. 

Describe  vaginitis  occurring  in  children  and  before  puberty. 

May  be  acute  or  chronic.  Acute  (rare),  due  to  injuries  and  rape 
(gonorrhoeal).  Symptoms  and  treatment  are  the  same  as  for  acute 
vulvitis.  Chronic  (more  common)  may  continue  from  acute  or 
be  caused  by  dentition,  errors  of  digestion,  pin-worms,  extension 
from  vulvitis. 


58  DISEASES   OF   THE    VAGINA. 

Symptoms. — Local  irritation,  milky  discharge,  unlike  the  secre- 
tion from  the  vulva.     The  vulva  is  usually  reddened  and  inflamed. 

Treatment. — Constitutional  tonics.  Local:  Cleanliness;  irriga- 
tion with  1  :  1000  bichloride  if  gonorrhocal,  or  weak  bichloride 
with  lime-water. 

What  are  the  varieties  of  vaginitis  in  adults  ? 

{acute 
chronic  ; 

(2)  Gonorrhoeal ; 

(3)  Granular,  papillary  ; 

(4)  Ulcerative,  adhesive,  or  senile  ; 

(5)  Cystic ; 

(6)  Follicular. 

Give  the  etiology,  symptoms,  diagnosis,  and  treatment  of  simple 
acute  catarrhal  vaginitis. 

Causes. — Predisposing,  anything  leading  to  congestion  of  the 
parts,  diseases  of  heart,  lungs,  and  liver,  abdominal  tumors,  preg- 
nancy, menstrual  epoch,  menopause,  chronic  constipation,  etc.  Ex- 
citing, exposure  to  cold  during  menstruation  ;  irritating  discharges 
from  the  cervix ;  cancer ;  putrid  contents  of  uterus ;  sloughing 
placenta  or  tumors  ;  abuse  of  sexual  intercourse  ;  too  hot  or  too 
cold  douches ;  use  of  local  irritants,  iodine,  etc. ;  foreign  bodies, 
sponges,  pessaries,  etc. ;  lacerations  and  contusion  during  parturi- 
tion ;  acute  exanthemata. 

Symptoms  and  Diagnosis. — Burning  heat  and  throbbing  in  the 
vagina,  sometimes  severe  pelvic  pain  of  a  bearing-down  character ; 
oifensive  purulent  leucorrhoea ;  burning  and  excoriation  at  the 
vulva ;  sensation  of  weight  in  the  perineum  ;  frequent  micturition. 
The  mucous  membrane  is  at  first  hot,  dry,  red,  and  swollen. 
AVithin  twenty-four  hours  there  is  an  acrid  discharge,  which 
becomes  rapidly  purulent  and  excoriates  the  vulva.  Through 
a  speculum  the  mucous  membrane  is  found  red  and  congested  with 
abrasions  and  ulcerations  on  the  surface. 

Complications. — Extension  of  the  inflammation  to  adjoining 
organs — uterus.  Fallopian  tubes,  peritoneum,  Bartholin's  glands, 
urethra,  bladder,  ureters,  and  kidneys. 

Treatment. — Put  the  patient  in  bed  on  a  low  diet.  Prescribe 
salines  internally,  and  use  opium  in  alkaline  diluents  for  the  bladder. 
Vaginal  injections  three  or  four  times  a  day  of  a  weak  solution  of 


INFLAMMATIONS   OF   THE    VAGINA.  59 

liq.  plumbi  subacetatis  or  boric  acid  in  warm  water.  Boric-acid 
dusting  powder  on  the  vulva.  Later  touch  the  vagina  with  nitrate 
of  silver,  gr.  xx-^j,  through  a  speculum. 

Give  the  etiology,  symptoms,  and  treatment  of  simple  chronic 
catarrhal  vaginitis. 

Etiology  same  as  acute.  From  chronic  leucorrhceal  discharges, 
as  in  phthisis,  chlorosis,  anaemia. 

Symptoms^  same  as  acute,  but  less  severe.  Difficult  to  differenti- 
ate from  gonorrhoeal :  in  90  per  cent,  gonorrhoeal. 

Treatment. — Daily  douches  of  hot  water  containing  alum,  sulph. 
5J-0j,  zinc  sulph.  3J,  or  boric  acid  ^ij-Oj.  Touch  vagina  once  in 
three  days  with  nitrate  of  silver,  gr.  x-xxx-^j. 

What  are  the  points  in  which  gonorrhoeal  vaginitis  differs  from 
simple  catarrhal  ? 

(1)  Symptoms  more  severe ;  (2)  onset  more  sudden  ;  (3)  greater 
liability  to  infect  other  organs,  such  as  urethra,  bladder,  uterus. 
Fallopian  tubes,  etc. ;  (4)  redness  and  excoriation  about  orifices 
of  Bartholin's  glands  are  more  common  ;  (5)  history  of  infection  ; 
(6)  gonorrhoeal  warts  and  buboes  ;  (7)  presence  of  gonococcus  of 
Neisser. 

What  is  the  frequency  of  gonorrhoeal  vaginitis  as  compared  with 
other  inflammations? 

Between  80  and  90  per  cent,  of  all  cases  of  vaginitis  are  prob- 
ably of  gonorrhoeal  origin. 

Is  the  vagina  as  apt  to  become  inflamed  as  other  genital  organs  ? 
No,  because  in  character  its  mucous  membrane  resembles 
the  skin.  A  gonorrhoeal  infection  will  frequently  pass  directly 
from  the  vulva  and  urethra  to  the  cervix  uteri  without  setting  up 
a  vaginitis. 

What  is  the  treatment  of  gonorrhoeal  vaginitis? 

General  treatment  is  the  same  as  for  catarrhal  vaginitis.  Irri- 
gate vagina  thoroughly  with  1  :  1000  bichloride  of  mercury.  It 
should  be  swabbed  out  through  a  speculum.  To  prevent  exten- 
tion  of  the  inflammation  to  the  cervix  it  is  well  to  paint  the  en- 
dometrium with  iodized  phenol  (iodine  gr.  xl  to  carbolic  acid  ,^j). 
Then  swab  out  the  vagina  with  nitrate  of  silver,  gr.  xx— 3J.  Pow- 
der the  surface  well  with  iodoform.  Separate  the  walls  with  tam- 
pons soaked  in  iodoform,  glycerin,  and  chloral  solution. 


60  ,   DISEASES   OF   THE   VAGINA. 

What  are  the  great  dangers  of  gonorrhoeal  vaginitis? 

(1)  Infection  of  the  endometrium  ;  (2)  infection  of  the  Fallopian 
tubes  and  the  formation  of  pyosalplnx  and  ovarian  abscess  ;  (3) 
pelvic  peritonitis. 

What  are  the  causes,  symptoms,  and  treatment  of  granular  vagi- 
nitis ? 

Causes. — It  may  result  from  either  of  the  preceding  forms,  but 
is  almost  always  associated  with  pregnancy. 

Symptoms. — The  subjective  symptoms  are  similar  to  those  of 
simple  vaginitis.  On  examination  numerous  granulations  are  felt 
scattered  over  the  mucous  membrane  and  cervix.  In  appearance 
they  resemble  a  raspberry.  The  granulations  are  due  to  a  swelling 
of  the  papillae,  either  individually  or  in  groups,  caused  by  round- 
cell  infiltration.     The  epithelium  on  the  surface  is  shed. 

Treatment. — Sulphate-of-copper  solution,  10  per  cent.,  applied  to 
granulations ;  crude  pyroligneous  acid,  poured  into  the  vagina 
through  a  Fergusson  speculum. 

Describe  ulcerative  vaginitis. 

The  condition  is  usually  met  with  in  women  past  the  menopause, 
and  affects  chiefly  the  epithelium.  It  consists  of  a  shedding  of 
the  epithelium  over  papilla?,  leaving  raw,  red,  angry-looking  patches. 
It  usually  affects  the  upper  third  of  the  vagina. 

Symptoms. — These  are  very  slight.  There  may  be  a  little  thin 
bloody  discharge  and  severe  pain.  It  tends  to  form  adhesions  be- 
tween the  vaginal  walls  and  between  the  vaginal  walls  and  cervix. 

Treatment. — Crude  pyroligneous  acid  poured  into  the  vagina 
through  a  Fergusson  speculum  or  bivalve  ;  the  vaginal  walls  and 
escoriated  patches  dusted  with  iodoform,  and  kept  separated  by  a 
strip  of  iodoform  gauze  or  a  tampon. 

Describe  cystic  vaginitis. 

Cystic  vaginitis  is  a  rare  condition,  the  cause  of  which  is  un- 
known. It  consists  of  numerous  little  cysts  which  contain  gas  or 
fluid  scattered  over  the  vaginal  walls.  These  are  produced  by  a 
swelling  of  the  rugae  into  folds,  adhesion  of  the  edges,  and  the 
formation  of  fluid  or  gas  in  the  interstices.  The  fluid  is  clear  and 
honey-like.     The  cysts  may  be  the  size  of  a  pea. 

Describe  follicular  vaginitis. 

Follicular  vaginitis  is  generally  of  gonorrhoeal  origin,  and  is  due 
to  inflammation  and  occlusion  of  the  mouths  of  the  follicles,  usually 


VAGINAL   CYSTS. — MALFORMATIONS   OF   VAGINA.  61 

at  the  upper  portion  of  the  vagina.  Retention  cysts  are  thus 
formed,  and  round-cell  infiltration  takes  place  in  the  tissue  sur- 
rounding the  gland.  On  digital  examination  these  cystic  follicles 
feel  like  shot  under  the  surface. 

Symptoms. — There  is  a  thick  leucorrhoeal  discharge. 

Treatment. — Open  each  cyst  with  a  knife  and  touch  with  nitrate 
of  silver. 

VAGINAL  CYSTS. 

Define  and  give  the  etiology  of  vaginal  cysts. 

These  are  small  cysts  which  appear  on  the  wall  of  the  vagina, 
usually  near  the  vulva,  but  they  may  be  seen  at  the  upper  portion. 
They  are  generally  due  to  the  collection  of  fluid  in  the  ducts  of 
Gartner  where  pervious.  Gartner's  ducts  are  the  horizontal 
tubes  of  the  parovarium  which  extend  toward  the  uterus  and  are 
lost  upon  the  anterior  vaginal  wall.  These  cysts  are  usually  single, 
and  contain  a  clear,  serum-like  fluid  or  a  dark,  chocolate-colored 
material.  Retention  cysts  are  sometimes  formed  by  the  enfolding 
and  adhesions  of  the  folds  of  the  vagina. 

Differentiation. — Cysts  of  Gartner's  duct  may  be  mistaken  for 
cystocele,  urethrocele,  and  prolapse. 

Symptoms. — Small  cysts  cause  no  symptoms.  When  large  they 
press  upon  neighboring  organs. 

Treatment. — Small,  none ;  large,  total  extirpation,  or  excising  a 
piece  of  the  sac-wall  and  sewing  the  edges  to  the  vaginal  wall. 

VAGINAL  ULCERS. 

What  varieties  may  be  met  with  ? 

(1)  Specific,  hard  and  soft  chancres  ; 

(2)  Non-specific,  resulting  from  one  or  other  of  the  preceding 
inflammatory  conditions. 

MALFORMATIONS  OF  VAGINA. 

Define  atresia  and  stenosis. 

A  complete  or  partial  obstruction  in  the  genital  tract.  The  word 
"atresia"  means  the  state  of  being  imperforate,  but  is  sometimes 
erroneously  used  in  place  of  stenosis  for  partial  closure. 

Describe  the  varieties  and  sites  of  atresia. 

It  is  congenital  or  acquired.     In  the  congenital  form  the  sites 


62  DISEASES   OF  THE  VAGINA. 

are  the  labia  minora,  hymen,  inner  part  of  vagina,  cervix  uteri. 
In  the  acquired  form  the  sites  are  the  vagina  and  cervix  uteri. 

In  the  congenital  form  the  labia  minora  are  usually  incomplete, 
permitting  the  passage  of  urine.  The  hymen  is  dense  and  thick- 
ened. 

Atresia  of  Vagina. — The  affection  is  due  to  atrophy  or  lack  of 
development  of  the  ducts  of  Miiller.  There  may  be  one  or  more 
transverse  membranes.  The  vagina  may  be  entirely  obliterated  or 
replaced  by  a  cord.  It  may  be  double,  or  one  tube  alone  developed. 
Septa  may  be  at  any  portion,  but  usually  near  the  uterus.  They 
may  be  single  or  multiple. 

In  the  cervix  the  atresia  may  be  at  the  os  internum  or  throughout 
the  whole  cervical  canal. 

What  are  the  causes  in  the  acquired  form  ? 

(1)  Injuries ;  (2)  chemical  agents ;  (3)  prolonged  labor  and 
injuries;  (4)  ulceration  and  adhesion  of  surfaces;  (5)  adhesive 
vaginitis  ;  (6)  gangrene. 

May  occur  at  any  time  after  puberty. 

The  symptoms  are  due  to  retained  menstrual  flow  and  interfer- 
ence with  coition.  Therefore  there  are  no  symptoms  before  puberty 
and  after  the  menopause. 

Amenorrhoea. — There  are  signs  of  menstruation,  but  no  flow,  and 
at  each  successive  menstrual  epoch  the  symptoms  become  worse 
and  more  prolonged,  the  intervals  shorter.  There  is  a  sense  of 
fulness  and  bearing  down  in  the  pelvis,  and  cramp-like  pain  ; 
finally,  the  retained  blood  forms  a  tumor  with  pressure  symptoms 
of  the  rectum  and  bladder. 

What  are  the  physical  signs? 

Inability  to  introduce  the  finger  into  the  vagina.  Rectal  exami- 
nation reveals  an  absence  of  the  vagina,  a  fibrous  cord,  or  a  tumor 
from  the  distension  of  the  vagina  with  blood. 

What  are  the  results? 

If  the  atresia  is  at  the  hymen  or  vulva,  a  very  large  tumor  may 
form.  The  uterus  is  generally  unaffected,  but  may  be  distended, 
forming  a  hrematometra.  The  tubes  may  be  filled  with  blood — haema- 
tosalpinx.  The  hymen  may  rupture  and  let  out  the  blood,  or  there 
may  be  a  rupture  of  the  vagina,  uterus,  or  Fallopian  tubes,  result- 
ing in  haematoccle,  peritonitis,  and  septicajmia. 


DISPLACEMENTS   OF   THE   VAGINA.  63 

If  the  atresia  is  nearer  the  uterus,  we  get  haematometra  and 
haematosalpinx. 

What  is  the  character  of  the  retained  blood  ? 

Before  the  menopause  it  is  dark,  grumous,  and  chocolate-colored, 
having  a  heavy  peculiar  odor.  After  the  menopause  it  is  clear, 
greenish,  and  honey-like. 

Differentiation  from  uterine  fibroids,  malignant  growths,  ovarian 
cysts,  hsematocele,  and  pregnancy. 

Treatment^  Operative. — If  the  atresia  is  at  the  hymen,  make  a 
crucial  incision  and  evacuate  the  blood,  either  slowly  or  rapidly, 
under  strictly  antiseptic  precautions.  Irrigate  thoroughly  and  insert 
a  glass  plug.  If  the  atresia  is  higher  up,  same  treatment.  If  there 
is  absence  of  vagina,  but  the  uterus  and  ovaries  can  be  palpated, 
make  an  artificial  vagina  with  a  knife  and  insert  a  glass  plug. 
When  the  atresia  is  at  the  cervix  the  retained  blood  should  be 
aspirated  slowly  to  prevent  rupture  of  a  distended  tube.  When 
thoroughly  evacuated,  dilate  the  cervix  and  use  copious  irrigation  ; 
insert  a  glass  plug.     The  irrigations  should  be  frequently  repeated. 

DISPLACEMENTS  OF   THE  VAGINA. 

What  are  they  ? 

Prolapse,  rectocele.  cystocele,  enterocele. 

Describe  prolapse  of  the  vagina. 

When  there  is  a  pouching  of  the  relaxed  walls  of  the  vagina  into 
its  own  canal,  so  that  it  rolls  down  toward  the  vulva,  the  condition 
is  known  as  prolapse.  The  condition  is  rare  without  coincident 
descent  of  the  bladder  (cystocele)  and  rectum  (rectocele),  owing 
to  the  attachment  of  the  vagina  to  these  organs.  Redundancy  of 
the  posterior  wall  without  rectocele  is  more  common  than  of  the 
anterior  without  cystocele. 

Pathology. — Any  influence  which  impairs  the  tone  of  the  vagi- 
nal walls,  such  as  subinvolution,  or  which  destroys  its  lower  sup- 
port, as  in  lacerations  of  the  perineum,  will  tend  to  induce  this 
affection.  It  is  very  rare  in  women  who  have  not  borne  children, 
and  is  frequently  associated  with  uterine  prolapse. 

Causes. — Repeated  parturitions,  rupture  of  perineum,  senile  atro- 
phy, subinvolution,  violent  exertion  of  abdominal  muscles. 

Symptoms. — It  may  be  acute,  due  to  sudden  violent  exertion,  or 
chronic,  the  result  of  months  or  years.     It  causes  a  sense  of  dis- 


64  DISEASES   OF   THE   VAGINA. 

comfort  in  the  vagina,  bearing-down  feeling,  sense  of  heat  and 
fulness  at  the  vulva.  Tendency  to  become  fatigued.  Presence 
of  a  tumor  is  felt  by  exploration.  The  mucous  membrane  may  be 
normal,  dark  purple  color,  eroded,  or  resembling  skin. 

Treatment. — Local  astringents  on  tampons  introduced  daily  in 
the  vagina ;  pessaries ;  abdominal  supports ;  surgical  operations.* 

Define  rectocele. 

This  is  a  prolapse  of  the  posterior  wall  of  the  vagina,  carrying 
with  it  a  portion  of  the  anterior  wall  of  the  rectum.  It  protrudes 
from  the  vulva  and  may  become  quite  large.  The  causes  are  the 
same  as  for  prolapse. 

Symptoms. — The  rectal  pouch  becomes  filled  with  impacted 
faeces,  is  irritated,  and  gives  rise  to  tenesmus,  discharge,  consti- 
pation, hemorrhoids.  The  finger  introduced  into  the  rectum  will 
decide  the  diagnosis. 

Treatment. — Same  as  for  prolapse.  When  large,  some  form  of 
posterior  colporrhaphy  is  always  performed. 

Define  cystocele. 

This  is  a  prolapse  of  the  anterior  wall,  dragging  with  it  the 
closely  adherent  bladder  and  urethra. 

Causes. — Same  as  for  prolapse.  When  the  vagina  ceases  to  give 
support  to  the  base  of  the  bladder,  to  which  it  is  attached,  a  cysto- 
cele results. 

Symptoms. — Diagnosis  can  be  made  by  passing  a  sound  into  the 
bladder.  Cystitis  due  to  fermentation  of  the  urine  remaining  in 
the  pouch  ;  vesical  tenesmus  ;  burning  on  urination.  It  may  form 
a  tumor  of  considerable  size,  protruding  through  the  vulva. 

Treatment. — When  large,  some  form  of  anterior  colporrhaphy  ; 
when  small,  same  as  for  prolapse.  A  Gehrung  pessary  will  eifect- 
ually  keep  up  a  prolapsed  anterior  wall. 

Describe  enterocele. 

This  is  very  rare,  and  consists  in  the  descent  of  a  portion  of 
small  intestine  into  the  pelvis,  encroaching  on  the  vaginal  canal. 
Usually  a  deep  Douglas  cul-de-sac.  It  may  attain  considerable 
size.  It  is  of  particular  importance  during  parturition,  when  the 
gut  may  become  strangulated. 

*  Colporrhaphies.     {See  Perineal  Operations.) 


THE  PERINEAL  BODY  AND  PELVIC  FLOOR.       65 

THE  PERINEAL  BODY  AND  PELVIC  FLOOR. 

ANATOMY. 
Describe  the  perineal  body. 

The  perineal  body  is  a  mass  of  fibro-muscular  tissue  filling  in 
the  space  between  the  lower  ends  of  the  rectum  and  vagina.  It  is 
an  irregular  four-sided  pyramid.  Two  sides  rest  against  the  pos- 
terior vaginal  wall,  one  against  the  anterior  wall  of  the  rectum, 
and  one  is  covered  by  the  skin  and  fascia  between  the  posterior 
commissure  and  the  anus.^  The  perineal  body  is  IJ  inches  in 
length,  1^^  inches  in  width,  and  f  inch  antero-posteriorly.  Above 
it  becomes  continuous  with  the  recto-vaginal  septum,  and  laterally 
it  is  bounded  by  fat.  The  whole  body  lies  below  a  line  joining 
the  tip  of  the  coccyx  and  the  subpubic  ligament. 

The  muscles  entering  into  its  formation  are  the  bulbo-cavernosus, 
the  transversus  perinei,  and  the  sphincter  and  levator  ani.  Its 
function  is  to  give  a  fixed  point  to  many  muscles,  to  prevent  pouching 
forward  of  the  rectal  wall,  and  to  give  strength  to  the  pelvic  floor. 
It  also  indirectly  supports  the  anterior  vaginal  wall  and  prevents 
cystocele. 

The  arterial  supply  of  the  perineum  is  derived  from  branches  of 
the  internal  pudic  ;  the  nerve-supply  from  the  pudic  nerve  ;  the 
veins  terminate  in  the  pudic  veins  and  the  lymphatics  in  the  in- 
guinal glands. 

Describe  the  pelvic  floor. 

The  pelvic  floor  includes  all  the  soft  parts  which  close  the  outlet 
of  the  pelvis :  rectum,  vagina,  bladder,  levator  ani,  and  coccygei 
muscles,  fascia  above  and  below  them,  perineal  body,  ischio-rectal 
fossae,  and  integument. 

Examining  the  structures  from  above  downward,  the  pelvic  and 
recto-vesical  fasciae  are  first  seen.  The  pelvic  fascia  is  attached  to 
the  pelvic  brim  and  to  the  tendinous  band  called  the  "  white  line  " 
which  extends  from  the  lower  portion  of  the  symphysis  pubis  to 
the  ischial  spine.  The  recto-vesical  fascia  is  the  continuation  of 
the  pelvic,  extending  downward  and  inward  from  the  white  line, 
covering  the  levator  ani  muscles  and  uniting  in  the  median  line 
with  its  fellow  of  the  opposite  side.  Posteriorly  it  is  continuous 
with  the  fascia  covering  the  pyriformis  muscle.  It  is  pierced  by 
the  vagina   and  rectum,  being  prolonged   downward  upon   each  in 

*  This  skin  is  often  erroneously  spoken  of  as  the  perineum. 
5— Gyn. 


66  THE   PERINEAL   BODY   AND   PELVIC   FLOOR. 

the  form  of  a  sheath.     The  obturator  fascia  is  the  other  division  of 
the  pelvic  fascia  at  the  white  line,  and  covers  the  obturator  muscle. 

Beneath  the  pelvic  and  recto-vesical  fascia  is  the  muscular 
diaphragm,  formed  by  the  levator  ani  in  front  and  the  coccygei 
behind. 

The  coccygei  are  two  thin,  triangular  muscles  which  arise  from 
the  ischial  spine  and  lesser  sacro-sciatic  ligament,  and  are  inserted 
into  the  lateral  borders  of  the  lower  segment  of  the  sacrum  and  to 
the  sides  and  anterior  surface  of  the  coccyx.  The  two  levatores  ani, 
meeting  with  each  other  in  the  median  line,  form  a  concave  mus- 
cular diaphragm  across  the  outlet  of  the  pelvis.  Each  arises  from 
the  posterior  aspect  of  the  pubis,  from  the  "  white  line,"  and  from 
the  inner  surface  of  the  ischial  spine.  They  extend  inward  to  the 
median  line,  uniting  with  each  other  and  surrounding  the  rectum 
and  vagina,  to  which  they  are  firmly  attached.^  Behind  the  vagina 
the  fibres  forn,i  part  of  the  perineal  body  and  blend  with  the  deep 
transversus  perinei  muscles.    Some  fibres  are  attached  to  the  coccyx. 

The  under  surface  of  the  levator  ani  is  covered  by  a  thin  mem- 
brane called  the  anal  fascia,  which  has  its  attachment  on  either 
side  to  the  obturator  fascia,  and  in  the  median  line  to  the  opposite 
lamina  and  to  the  rectum  and  vagina.  Below  the  anal  fascia  the 
remainder  of  the  pelvic  outlet  is  filled  by  the  perineal  body  and 
the  ischio-rectal  fossae. 

What  muscles  enter  into  the  formation  of  the  perineal  body  ? 

The  hulho-cavernosi  arise  posteriorly  in  the  perineal  body  and 
encircle  the  vaginal  bulbs.  Each  divides  into  three  slips — one 
going  to  the  posterior  surface  of  the  bulb,  another  to  the  lower 
surface  of  the  corpus  cavernosum,  and  the  third  being  lost  on  the 
mucous  membrane  of  the  vestibule.  Their  action  is  to  compress 
the  bulbs. 

The  transversus  perinei  muscles  are  divided  into  two  layers,  a 
superficial  and  a  deep,  separated  by  the  anterior  layer  of  the  tri- 
angular ligament.  They  arise  from  the  rami  of  the  ischium  and 
the  anterior  triangular  ligament,  and  are  inserted  into  the  median 
raphe  of  the  perineal  body. 

The  sphincter  ani  arises  from  the  tip  of  the  coccyx  and  superficial 
fascia,  and  is  inserted  into  the  perineal  body. 

The  levator  ani  has  been  described.  It  is  divided  into  an 
anterior  or  j;?<?>o-i;cf^m<7i  portion,  which  surrounds  the  vagina  and 

*  The  vagina  pierces  the  pelvic  floor  at  an  angle  of  about  00°. 


LACERATIONS   OF    PERINEUM   AND    PELVIC   FLOOR.        67 

acts  to  contract  the  outlet,  and  a  posterior  portion,  the  obturato- 
coccygeal,  surrounding  the  rectum. 

The  urethra  is  surrounded  by  the  compressor  iirethrse  muscle 
(called  by  some  the  sphincter  or  constrictor  vaginae),  which  forms 
a  figure  of  8  around  the  vagina  and  urethra. 

Describe  the  ischio-rectal  region. 

This  corresponds  to  the  portion  of  the  pelvic  outlet  behind  the 
perineal  hodj.  It  contains  the  termination  of  the  rectum  and  a 
deep  fossa  filled  with  fat  on  either  side  of  the  latter,  between  it  and 
the  tuberosities  of  the  ischium.  The  ischio-rectal  fossse  are  pyra- 
midal in  shape,  with  the  apex  directed  upward.  They  are  one  inch 
in  breadth  and  two  inches  in  depth,  bounded  internally  by  the 
levator  ani,  sphincter  ani,  and  coccygei  muscles,  externally  by  the 
tuberosities  of  the  ischium  and  the  obturator  fascia ;  anteriorly 
they  are  limited  by  the  division  of  the  superficial  and  deep  perineal 
fascia,  posteriorly  by  the  gluteus  maximus  and  great  sacro-sciatic 
ligament. 

The  external  covering  of  the  pelvic  floor  is  made  up  of  skin 
and  fascia. 

Describe  the  superficial  perineal  fascia. 

It  is  separated  into  two  layers — a  superficial  and  a  deep.  The 
superficial  or  subcutaneous  layer  contains  considerable  adipose 
tissue  and  the  superficial  perineal  and  hemorrhoidal  vessels  and 
nerves.  The  deep  layer  is  attached  to  the  rami  of  the  pubes  and 
ischium  posteriorly,  and  curves  around  the  transversus  perinei  to 
become  continuous  with  the  anterior  layer  of  the  triangular  liga- 
ment. 

The  trianpdar  ligament,  or  deep  perineal  fascia,  is  composed  of 
two  layers,  and  closes  the  front  part  of  the  outlet  of  the  pelvis. 
It  is  attached  to  the  under  surface  of  the  symphysis  and  to  the 
pubic  and  ischial  rami.     It  is  divided  in  the  middle  by  the  vagina. 

LACERATIONS   OF    THE    PERINEUM  AND    PELVIC 

FLOOR. 

What  are  the  chief  facts  to  be  borne  in  mind  in  the  consider- 
ation of  lacerations  of  the  perineum  ? 

A  thorough  knowledge  of  the  anatomy  and  functions  of  the  peri- 
neum and  pelvic  floor  is  necessary  to  fully  understand  the  import- 
ance of  these  lesions.     The  levator  ani  muscles  and  pelvic  fascia 


68  THE   PERINEAL    BODY   AND    PELVIC   FLOOR. 

are  the  most  important  features  in  the  support  of  the  pelvic  vis- 
cera, acting  as  a  tight  sling  of  fibres  across  the  pelvic  outlet. 
Laceration  or  overstretching  of  these  fibres,  especially  posteriorly 
at  their  attachment  to  the  rectum,  results  in  a  relaxation  of  the 
outlet  through  which  the  superincumbent  structures  roll  out,  caus- 
ing rectocele,  cystocele,  prolapse  of  the  vagina  and  uterus. 

What  are  the  causes  of  lacerations  of  the  perineum  ? 

Parturition  is  by  far  the  most  important  cause;  acting,  when 
there  is  a  large  head,  in  occipito-posterior  position,  rotated  into 
the  hollow  of  the  sacrum  ;  when  there  is  a  narrow  pubic  arch ;  in 
elderly  primiparae,  with  rigidity  of  the  parts  ;  the  careless  use  of  for- 
ceps, etc.  Besides  parturition,  lacerations  may,  rarely,  be  produced 
by  external  violence,  such  as  falling  astride  sharp  objects.  Rape 
in  children  sometimes  results  in  a  laceration,  as  may  also  syphilitic 
ulcerations  of  the  perineal  body.  Occasionally  there  is  a  loss  of  the 
perineal  body  due  to  senility,  debility,  and  subinvolution. 

What  are  the  varieties  of  perineal  lacerations  ?  * 

(1)  Laceration  into  the  body  of  the  perineum,  including  slight 
tears  and  those  extending  to  the  sphincter  without  injury  to  the 
levator  ani.  (2)  Rupture  of  the  perineum  with  radiating  tears  into 
the  sulci  on  either  side  of  the  posterior  columns  of  the  vagina. 
These  are  the  Y-shaped  tears  which  leave  the  tip  of  the  posterior 
column  as  a  tongue  of  tissue.  The  laceration  may  extend  upon 
one  or  both  sides.  (3)  Rupture  of  perineal  body  through  the 
sphincter  ani  without  laceration  of  the  levator  ani.  (4)  Lacera- 
tion through  the  sphincter  ani  with  injury  to  the  levator  ani.  (5) 
Invisible,  concealed,  or  subcutaneous  ruptures  when  the  levator  ani 
muscles  and  fascia  have  been  overstretched  and  torn,  resulting  in 
subinvolution  and  relaxation  of  the  vaginal  outlet.  These  kinds 
of  laceration  are  the  most  frequent  and  of  the  greatest  importance. 
They  are  generally  unrecognized. 

How  would  you  test  for  relaxation  of  the  vaginal  outlet  and  the 
extent  of  laceration  ? 

By  placing  two  fingers  in  the  vagina  and  pressing  downward  and 
outward,  at  the  same  time  telling  the  patient  to  bear  down  as  if  at 
stool.  If  relaxation  exists,  the  walls  of  the  vagina  will  be  seen  to 
bulge  downward  and  protrude.  It  is  well  to  place  a  pledget  of  cot- 
ton over  the  anus  to  prevent  evacuation  of  fsBces.     To  test  the 

*  Taken  from  Dr.  Cleveland's  classification. 


OPERATIONS    FOR    LACERATION    OF    PERINEUM.  69 

extent  of  laceration  place  the  thumb  against  the  anterior  margin 
of  the  anus,  and  the  tip  of  the  finger  just  within  the  vagina,  and 
bring  the  two  together. 

What  is  the  significance  of  rupture  of  the  perineum  ? 

Septicaemia  may  be  an  immediate  consequence,  due  to  the  expos- 
ure of  the  extensive  raw  surface,  rich  in  blood-  and  lymph-vessels, 
to  the  lochial  fluid. 

Tears  through  the  sphincter  will  lead  to  complete  or  partial  incon- 
tinence of  fasces.  Tears  involving  the  levator  ani  muscles  and 
fascia  will  result  in  subinvolution,  relaxation  of  the  vagina,  prolapse 
of  uterus  and  vagina,  rectocele,  cystocele,  subinvolution  of  the  ute- 
rus, and  displacements.  Tendency  to  abortion,  tenderness  at  the 
site  of  the  tear,  may  result.  Sometimes  air  enters  the  vagina  and 
escapes  with  a  noise. 

What  are  the  symptoms  of  lacerated  perineum  ? 

These  are  due  to  the  above  consequences,  and  have  been  described 
under  Rectocele  and  Cystocele. 

OPERATIONS. 
What  are  the  two  classes  of  operations  ? 

Primary  and  secondary.  The  primary  operation,  or  immediate 
repair  of  the  injury  at  the  close  of  labor,  belongs  to  the  province 
of  obstetrics.  It  should  be  the  object  in  performing  the  secondary 
operation  to  reduce  the  tear  by  proper  denudation  to  its  original 
condition — i.  e.  the  recent  form — and  then  to  suture. 

How  long  should  you  wait  after  labor  before  performing  the  sec- 
ondary operation? 

It  is  better  to  wait  until  involution  is  complete,  and  operate  from 
five  to  six  months  after  confinement. 

What  are  the  preliminary  preparations  and  instruments  required 
for  a  primary  operation  ? 

Regulate  the  patient's  diet  for  two  or  three  days  previous  to  the 
operation.  Grive  a  mild  laxative  for  two  nights  before  to  secure 
complete  evacuation  of  the  bowels.  An  enema  should  be  admin- 
istered and  the  bladder  emptied  immediately  before  operating.  The 
patient  is  then  anaesthetized  and  placed  in  the  lithotomy  position, 
the  knees  being  held  up  by  a  Clover's  crutch.  The  vulva  should 
be  shaved  and  thoroughly  cleaned  with  1  :  1000  bichloride,  and  the 


70 


THE    PERINEAL   BODY   AND   PELVIC   FLOOR. 


vagina  thoroughly  swabbed  out  with  the  same  solution.  The  abdo- 
men and  limbs  of  the  patient  are  surrounded  with  towels  wrung 
out  of  1  :  1000  bichloride. 

The  necessary  instruments  are  2  pairs  of  sharp-pointed  scissors, 
straight  and  curved  on  the  flat ;  1  pair  of  straight,  blunt-pointed 
scissors  ;  1  pair  of  sharp-pointed  straight  scissors,  curved  on  the 
side  ;  4  tenacula,  Emmet's ;  2  bullet  forceps ;  6  sponge-holders ; 
1  needle-holder  ;  2  mouse-toothed  forceps  ;  1  plain  dissecting  for- 
ceps ;  1  pair  of  tissue  forceps  ;  6  pairs  of  artery  forceps  ;  1  counter- 
pressure  hook ;  1  shield ;  1  Emmet's  twisting  forceps ;  12  per- 
forated  shot;  1   shot-compressor;  12   needles,  small   curved,  large 

Fig.  23. 


Method  of  Repair  adopted  in  Previous  Cases. 


curved,  spear-point,  long,  straight ;  1  Peaslee's  needle  ;  sterilized 
catgut,  sizes  Nos.  2  and  3 ;  small-size  silk ;  silkworm  gut ;  silver 
wire,  No.  24  ;  Kelly's  rubber  pad. 


OPERATIONS    FOR   LACERATION   OF   PERINEUM. 


71 


What  are  the  most  important  operations? 

Perineorrhaphies  and  posterior  colporrhaphies  :  (1)  Tait's  flap- 
splitting  perineorrhaphy  for  complete  laceration;  (2)  Tait's  flap- 
splitting  perineorrhaphy  for  incomplete  laceration,  modified  by 
Sanger ;  (3)  Cleveland's  perineorrhaphy ;  (4)  Hegar's  posterior 
colporrhaphy  ;  (5)  Emmet's  posterior  colporrhaphy. 

Describe  Tait's  perineorrhaphy? 

This  operation  is  based  on  the  principles  of  the  healing  of  an  old 
tear.  If  the  buttocks  and  labia  are  widely  separated,  a  white  line 
of  cicatrix  will  be  seen  extending  from  side  to  side  transversely  to 
the  axis  of  the  old  wound.  The  object  of  the  operation  is  to 
restore  the  old  rent,  and  unite  it  in  a  vertical  axis — i.  e.  at  right 
angles  to  the  present  cicatrix. 

The  patient  is  prepared  as  described.  An  assistant  stands  on 
either  side,  the  one  on  the  right  holding  an  irrigator  nozzle  and 
allowing  a  slight  stream  of  1  :  10,000  bichloride  to  trickle  over  the 
parts  during  the  operation.  A  tampon  is  introduced  into  the  rec- 
tum. The  middle  finger  of  the  left 
hand  is  then  inserted  into  the  rec- 
tum and  the  buttocks  and  labia 
strongly  separated  by  an  assistant, 
so  that  the  cicatrix  is  put  on  a 
stretch.  The  point  of  an  angular 
pair  of  scissors  is  introduced  into 
the  extreme  end  of  the  cicatrix  on 
one  side,  and  run  through  to  the 
other  extremity.  From  each  end 
of  this  incision  another  is  carried 
forward  to  the  bases  of  the  labia 
minora,  and  again  backward  for 
one-third  of  an  inch  ;  the  edges  of 
the  upper  flap  a  are  caught  with 
a  pair  of  tissue  forceps  and  dis- 
sected upward,  the  same  being  done 
to  the  lower  flap  h  downward, 
and  the  wound  assumes  the  shape 

represented  by  the  dotted  lines  in  Fig.  24.  The  sutures  are 
now  introduced  by  means  of  a  Peaslee's  needle  well  curved,  which 
is  run  through  from  side  to  side,  entered,  and  brought  out  just 
within  the  margin  of  the  denuded  area.     This  is  threaded  with 


/ 


Fig.  24. 


Va^na 


Rectum 


72  THE    PERINEAL    BODY    AND    PELVIC    FLOOR. 

silkworm  gut  and  withdrawn.  The  sutures  are  then  tied  and  the 
edges  of  the  skin  brought  together  by  intermediary  superficial 
sutures.  The  rectal  and  vaginal  flaps  fold  in  on  each  other  and, 
retracting,  point  to  the  rectum  and  vagina  respectively.  The 
resulting  cicatrix  is  linear,  and  leaves  scarcely  any  trace  after 
healing. 

What  are  the  advantages  of  this  operation  ? 

(1)  No  tissue  is  removed,  the  recto-vaginal  septum  is  simply  split, 
the  flap  turned  up,  sides  /  denuded  and  united.  (2)  The  sutures 
are  all  external.  (3)  The  parts  are  brought  back  into  their  original 
position. 

What  additional  method  of  repair  may  be  done  in  case  the  lace- 
ration extends  through  the  sphincter  ani  and  up  the  recto- 
vaginal septum? 

After  dissecting  up  the  vaginal  flap  as  just  described,  a  V-shaped 
denudation  is  made  with  its  apex  up  the  rectum.  The  ends  of  each 
arm  of  the  V  lie  against  the  separated  ends  of  the  sphincter  ani. 
which  can  be  seen  as  little  retracted  dimples  on  either  side  of  the 
anal  opening.  Rectal  sutures  of  silkworm  gut  are  then  introduced, 
beginning  at  the  apex,  and  are  tied  in  the  rectum.  The  ends  of 
the  sutures  are  left  long,  and  protrude  from  the  anus.  A  suture 
of  silver  wire  may  be  passed  around  the  inverted  V. 

It  is  well  to  introduce  the  perineal  sutures  first,  in  order  to 
avoid  stretching  the  rectum,  whose  edges  have  just  been  brought 
together.     The  rectal  sutures  may  be  left  in  for  several  weeks. 

Describe  the  Sanger-Tait  operation. 

This  operation  differs  only  in  detail  from  the  one  just  described. 
The  middle  finger  alone,  or  the  index  and  middle  fingers,  may  be 
introduced  into  the  rectum.  The  points  of  a  pair  of  curved  scissors 
are  inserted  into  the  recto-vaginal  septum  between  the  cicatrix  and 
the  margin  of  the  anus,  and  pushed  upward  to  the  crest  of  the 
rectocele.  The  septum  is  now  split  before  making  the  horizontal 
incision.  This  avoids  undue  hemorrhage.  Sanger  also  recommends 
a  thin-bladed  knife  to  be  used  for  this  splitting  instead  of  scissors. 
The  horizontal  incision  may  now  be  made,  running  out  to  a  point 
on  cither  side  vertically  below  the  extremities  of  the  nymphae, 
and  then  carried  upward  to  the  bases  of  the  labia  minora,  or 
the  incision  may  be  curved  in  the  form  of  a  U.  The  dissection 
of  the  flap  is  now  completed.     Silver-wire  sutures  instead  of  silk- 


OPERATIONS  FOE  LACERATION  OF  PERINEUM. 


73 


worm  gut  are  introduced  by  means  of  a  straight  needle  threaded 
with  carrying  thread.  The  rectal  tampon  is  removed,  and  the 
sutures  twisted  up  and  shotted.  Intermediary  silkworm-gut 
sutures  are  required. 

Describe  Cleveland's  operation. 

After  the  usual  preparations  the  patient  is  anaesthetized  and 
placed  in  the  lithotomy  position,  as  just  described  for  Tait's  opera- 
tion. The  field  of  operation  is  put  on  the  stretch  by  two  tenacula 
hooked  into  the  bases  of  the  labia  majora  on  either  side  and  re- 

FiG.  25. 


Cleveland's  Suture  for  Lacerated  Perineum. 


tracted.  The  crest  of  the  rectocele  is  caught  with  a  pair  of  bullet 
forceps  and  drawn  up  by  an  assistant.  A  triangular  area  is  now 
denuded,  having  for  its  base  the  line  joining  the  two  lateral  tenacula, 
and  for  its  apex  the  crest  of  the  rectocele.     The  denudation  may 


74 


THE   PERINEAL    BODY   AND   PELVIC   FLOOR. 


be  made  with  a  knife  or  pair  of  scissors.  After  thoroughly  irri- 
gating the  parts  the  sutures  are  passed  in  the  following  manner : 
A  long  straight  needle,  threaded  with  catgut,  size  No.  3,  is  inserted 
at  the  point  1  A  in  the  figure,  carried  to  the  mid-line,  as  shown  by 
the  dotted  lines,  and  brought  out.  The  needle  is  then  introduced 
where  it  came  out,  and,  curving  downward,  is  brought  out  at  2  A. 
The  catgut  is  now  drawn  through,  and  the  needle  again  introduced 
at  3  A,  carried  up  to  the  mid-line  crossing  the  loop,  and  is  brought 
out  at  4  A,  finishing  the  first  suture,  iV.  The  second  suture,  B,  is 
passed  as  indicated  by  the  dotted  lines.  In  the  figure  the  apex  of 
the  triangle  is  shown  foreshortened.  A  third  suture.  E,  is  now 
passed  as  in  the  figure.  Suture  A  is  first  tightened  and  tied, 
making  a  figure  of  8  and  really  two  sutures.  Next  B  is  brought 
together,  making  another  figure  of  8,  and  finally  E  is  tied.  The 
advantages  of  this  operation  are  the  rapidity  with  which  it  can  be 
performed  and  its  applicability  to  primary  as  well  as  secondary  tears. 

Describe  Hegar's  operation. 

The  patient  is  prepared  in  the  usual  manner  and  placed  in  the 
lithotomy  position.  Two  tenacula  are  fixed  in  the  lowest  part  of 
the  labia  majora,  points  B  and  C,  and  drawn  forcibly  to  both  sides 

Fig.  2G. 


Hegar's  Operation,  foreshortened. 

by  assistants.     The  cervix  is  caught  by  its  posterior  lip  with  a  pair 
of  bullet  forceps  and  drawn  downward,  forward,  and  lifted  up,  as 


OPERATIONS    FOR    LACERATION   OF   PERINEUM. 


75 


shown  in  the  figure.  A  triangular  area  is  now  marked  out  with  a 
knife,  having  for  its  base  the  line  B  C,  which  runs  across  the  pos- 
terior commissure,  and  for  its  apex  A,  a  point  just  below  the  cervix. 
The  mucous  membrane  is  denuded  from  this  triangular  area,  either 
with  a  knife  dissecting  down  a  flap  from  the  apex  A,  or  with  a  pair 
of  scissors.  The  sutures  are  of  silver  wire  for  the  vaginal,  and  silk 
for  the  perineal,  and  are  both  deep  and  superficial.  The  deep 
sutures  are  introduced  one-third  of  an  inch  apart,  underlying  the 
whole  denuded  area.  The  superficial  sutures  unite  the  mucous 
membrane  between  each  of  the  deep  sutures. 

What  modifications  of  this  operation  may  be  made  with  advan- 
tage? 

The  area  of  denudation  may  be  brought  together  with  a  continu- 
ous catgut  suture  in  layers,  as  used  by  Martin  in  his  anterior  col- 
porraphy,  to  be  described.  The  apex.  A,  may  be  taken  at  a  little 
above  the  highest  point  on  the  crest  of  the  rectocele  and  held  up 
with  bullet  forceps. 

Describe  Emmet's  operation. 

This  operation  is  more  especially  advantageous  when  the  tear 
takes  a  Y-shaped  form  up  the  sulci,  and  when  there  is  considerable 
relaxation. 

Preparation  of  the  pa- 
tient is  done  as  usual, 
and  she  is  placed  in  the 
lithotomy  position.  A 
point  on  the  crest  of  the 
rectocele,  A,  is  caught 
with  a  tenaculum.  Two 
other  tenacula  are  intro- 
duced into  the  lowest 
caruncles  of  the  hymen 
on  either  side,  C  and  B. 
These  three  points  are 
approximated  at  the  end 
of  the  operation.  The 
points  D  and  E  are  in 
the  sulci  on  either  side 

of  the    column    of    the  ^ 

vagina.     Two  triangular  ^""^ 

areas,  A  D  B  and  A  E  C,  Emmet's  Operation. 


Fig.  27. 


76  THE    PERINEAL    BODY    AND    PELVIC    FLOOR. 

Fig.  28. 


el^^' 


Emmet's  Operation  :  Insertion  of  Sutures. 

are  thus  formed,  and  are  now  denuded  as  follows :  An  assistant  draws 
the  crest  A  first  strongly  to  the  operator's  left  side,  making  the  lines 

A  D  B  nearly  straight.     The  mucous 
Fig  29.  membrane  extending  along  this  line  is 

now  stripped  up  with  scissors.  The 
same  thing  is  done  for  the  opposite 
side,  drawing  the  tenaculum  at  A  to 
the  right.  Denudation  of  the  whole 
area  shown  in  the  figure  is  then  com- 
pleted with  scissors.  The  edges  of  the 
lateral  triangles  are  united  together 
with  sutures  carried  deep  into  the  sulci 
and  entirely  under  the  denuded  area, 
so  as  to  catch  up  the  ends  of  the  sep- 
arated fibres  of  the  pelvic  fascia.  The 
manner  in  which  the  sutures  are  passed 
is  shown  in  Fig.  28.  There  remains 
now  a  small  area  to  be  united  on  the 
perineal  surface  with  silk  or  wire  su- 
tures. 

Describe  Martin's  anterior  colporrha- 
phy  for  cystocele  and  prolapse. 

The  usual  preliminaries  having  been 

gone  through  with  in  the  preparation 

of  the  patient,  she  is  anaesthetized  and 

placed  in  the  lithotomy  position.     The 

anterior  lip  of  the  cervix  is  grasped  with  a  pair  of  bullet  forceps 

and  well  drawn  down.     This  exposes  the  anterior  wall  of  the  vagina. 


B 

Martin's  Suture. 


THE  URETHRA  AND  BLADDER.  77 

Another  pair  of  bullet  forceps  is  placed  just  below  the  urethra 
and  drawn  up.  The  whole  surface  is  put  on  the  stretch  by  lateral 
tenacula.  Then  an  incision  is  made  around  an  ovoid  figure  which 
has  one  point  just  below  the  urethra  and  the  other  near  the  cervix. 
This  area,  marked  out  by  the  line  of  incision,  and  which  includes 
to  a  greater  or  lesser  extent  the  anterior  wall  of  the  vagina,  is  now 
denuded  with  a  knife,  dissecting  down  a  flap,  or  with  a  pair  of 
scissors.  Suturing  of  the  area  is  now  performed  as  follows  :  A 
long  No.  2  catgut  suture  is  threaded  into  a  medium-sized  spear- 
point  needle,  and  passed  through  at  the  apex  A  and  tied.  The  end 
of  the  suture  is  given  to  an  assistant  to  hold,  and  the  bullet  forceps 
are  removed.  The  needle  is  then  inserted  into  the  denuded  area, 
passed  under  the  surface,  and  brought  into  the  denuded  area  as 
shown  in  Fig.  29.  In  this  way,  with  an  over-and-over  continuous 
stitch,  the  suture  is  carried  to  the  inferior  angle  B,  then  back  again 
to  the  top  in  the  same  manner,  until  the  edges  of  the  mucous  mem- 
brane are  brought  near  enough  together  to  approximate  by  addi- 
tional sutures. 

THE  URETHRA  AND  BLADDER. 

ANATOMY. 
Describe  the  urethra. 

The  urethra  is  a  canal  If  inches  in  length,  extending  from  the 
meatus  to  the  neck  of  the  bladder.  Its  lower  three-fourths  is  im- 
bedded in  the  anterior  vaginal  wall;  its  upper  fourth  is  firmly 
bound  to  the  vagina  by  connective  tissue.  It  extends  upward  and 
backward  parallel  to  the  plane  of  the  pelvic  brim. 

The  mucous  membrane  is  covered  with  squamous  epithelium  at 
its  lower  part,  and  transitional  epithelium,  like  the  bladder,  at  its 
upper  position.  It  contains  mucous  glands,  papillae,  lacunae,  and 
villous  tufts.  On  cross-section  the  urethra  is  seen  to  be  slit-shaped 
transversely  at  its  vesical  end,  and  stellate  below.  Just  within  the 
meatus,  on  either  side,  are  the  orifices  of  Skene's  tubes  or  ducts. 
These  extend  along  the  floor  of  the  urethra,  beneath  the  mucous 
membrane,  upward  for  a  distance  of  three-fourths  of  an  inch. 

The  muscular  coat  consists  of  two  layers  of  unstriped  fibres,  an 
internal  longitudinal  and  an  external  circular. 

Describe  the  bladder. 

The  bladder  is  a  hollow  muscular  organ   situated  between  the 


78  THE  URETHRA  AND  BLADDER. 

symphysis  in  front  and  the  uterus  and  vagina  behind.  Its  shape 
when  empty  is  like  the  letter  Y.  The  upper  and  lower  walls, 
coming  in  contact,  form  the  two  horizontal  arms.  The  urethra  forms 
the  vertical  arm.  It  has  opening  into  it  the  internal  orifice  of  the 
urethra  and  the  two  ureters:  the  latter,  one  on  cither  side,  are  IJ 
inches  from  each  other  and  from  the  urethra. 

The  bladder  is  divided  into  a  body,  neck,  and  base. 

The  hoilij  is  "  all  that  portion  of  the  organ  lying  above  an  imagi- 
nary line  drawn  from  the  ureteric  openings  to  the  symphysis  pubis  " 
(Skene).  All  below  is  the  base,  and  includes  the  trigone  (that 
triangular  portion  between  the  ureteric  openings  and  the  inter- 
nal orifice  of  the  urethra)  and  the  has-fond  (that  portion  behind 
the  openings  of  the  ureters,  which  in  old  subjects  may  be  a  deep 
pouch).  The  neck  is  the  thickened  portion  surrounding  the 
urethral  orifice. 

The  bladder  is  composed  of  three  coats,  mucous,  muscular,  and 
peritoneal.  The  mucous  membrane  is  thrown  into  numerous  folds, 
and  is  lined  with  several  layers  of  transitional  epithelium  and  a 
superficial  squamous  layer.  It  is  loosely  attached  to  the  submucous 
tissue,  except  at  the  trigone,  and  is  thicker  at  the  urethral  open- 
ing, where  it  has  a  valve-like  function  to  prevent  the  escape  of 
urine  (Hart  and  Barbour).  The  muscular  coat  is  composed  of  three 
irregular  layers  of  unstriped  fibres,  an  external  and  internal  longi- 
tudinal and  a  middle  circular.  At  the  openings  the  circular  fibres 
are  more  developed  and  have  a  sphincteric  action. 

The  peritoneal  coat  covers  the  fundus  and  part  of  the  posterior 
bladder-wall,  from  which  it  is  reflected  on  to  the  anterior  surface 
of  the  uterus  at  the  level  of  the  isthmus,  forming  the  vesico- 
uterine ligaments  and  pouch.  The  arterial  supply  is  derived  from 
the  utero-vesical  branches  of  the  anterior  division  of  the  internal 
iliac  and  from  the  uterine  artery. 

The  urethra  is  supplied  from  the  vaginal  arteries. 

The  veins  form  plexuses  outside  the  muscular  coat,  and  unite 
with  those  of  the  uterus,  vagina,  nymphae,  and  rectum.  They 
empty  into  the  internal  iliac  vein.  The  plexus  of  the  urethra  com- 
municates with  that  of  the  vagina. 

The  lymphatics  accompany  the  veins,  and  enter  the  hypogastric 
glands  near  the  internal  iliac  artery.  The  nerves  are  derived  from 
the  hypogastric  plexus  of  the  sympathetic,  and  from  the  third  and 
fourth  sacral,  the  latter  supplying  mainly  the  base  and  neck. 


DISEASES   OF   THE   URETHRA   AND   BLADDER.  79 

Describe  the  course  of  the  ureters. 

At  the  brim  of  the  pelvis  the  ureters  cross  over  the  iliac  vessels 
just  below  the  division  of  the  common  iliacs.  Here  the  left 
ureter  lies  behind  the  sigmoid  flexure  of  the  colon,  and  the  right 
behind  the  lower  end  of  the  ileum.  They  then  run  downward, 
backward,  and  outward  along  the  pelvic  wall  until  near  the  ischial 
spines.  Here  they  bend  downward,  forward,  and  inward  behind  the 
uterine  arteries,  passing  beneath  the  bases  of  the  broad  ligaments. 
At  the  level  of  the  os  uteri  externum,  and  three-fifths  of  an  inch 
distant  from  the  uterus,  the  uterine  arteries  cross  the  ureters. 
From  this  point  they  continue  to  converge,  lying  in  relation  to  the 
anterior  vaginal  and  posterior  bladder-walls,  and  pierce  the  latter 
obliquely  at  a  point  one-half  to  three-fourths  of  an  inch  in  front 
of  and  below  the  cervix.  They  run  for  a  distance  of  half  an  inch 
in  the  muscular  coat,  still  converging,  so  that  their  internal  open- 
ings are  separated  from  each  other  by  about  one  and  a  half  inches. 

DISEASES  OF  THE  URETHRA  AND   BLADDER. 

What  are  the  diseases  to  which  the  urethra  is  liable? 

Malformations  (hypospadias),  urethral  caruncle,  (see  p.  56),  and 
prolapse  of  the  mucous  membrane  (see  p.  57),  inflammation  (ure- 
thritis), urethrocele. 

Give  the  etiology,  symptoms,  and  treatment  of  urethritis. 

It  is  nearly  always  due  to  gonorrhoeal  infection,  but  may  be  simple. 
The  chronic  form  may  be  caused  by  caruncles  or  chronic  cystitis. 

Symptoms. — Dysiiria,  muco-purulent  discharge. 

Treatment. — Tepid  irrigations,  application  of  nitrate  of  silver, 
iodoform  bougies.  Skene's  tubules  may  become  inflamed  and  keep 
up  a  urethritis  until  they  are  slit  up  and  cauterized. 

Give  the  etiology,  symptoms,  and  treatment  of  the  acute  and 
chronic  forms  of  cystitis. 

Etiology. — Acute  :  gonorrhoea  ;  exposure  to  cold  ;  injuries  dur- 
ing parturition  ;  peritonitis.  Chronic  :  continuance  from  acute  ; 
stone  in  the  bladder ;  pressure  of  a  tumor  or  uterus  on  the  blad- 
der ;  pyelonephritis. 

Symptoms. — Acute  :  severe  pain  over  the  bladder  ;  chill,  fever  ; 
painful  micturition  ;  high-colored  urine.  May  last  a  few  days  to  a 
week,  and  subside  or  pass  on  to  the  chronic  form.  Chronic :  Fre- 
quent micturition,  more  especially  at  night ;  vesical  tenesmus  and 


80  THE  URETHRA  AND  BLADDER. 

sensation  of  weight  over  the  bladder ;  cloudy,  scanty  urine,  con- 
taining pus-cells  and  cells  from  the  bladder.  It  may  debilitate  the 
whole  system  and  cause  the  patient's  health  to  be  undermined. 
The  walls  of  the  bladder  may  become  encrusted  with  lime  and  other 
salts,  which  give  rise  to  stone  in  the  bladder. 

Treatment. — Acute :  rest  in  bed  ;  hot  poultices  over  the  lower 
part  of  the  abdomen  ;  demulcent  drinks  of  flaxseed  tea  and  muci- 
lage ;  opium  to  check  the  pain.  Chronic:  The  administration  of 
alkaline  diluents,  such  as  citric  acid,  acetate  of  potassium,  uva 
ursi,  lithia-water  ;  unirritating  diet.  Washing  out  the  bladder  with 
a  1  :  1000  solution  of  boric  acid  by  means  of  a  double-current  cathe- 
ter and  fountain  syringe  ;  may  be  done  twice  daily  if  necessary  or 
every  other  day.  The  pain  is  relieved  by  morphine  suppositories. 
If  all  these  means  fail,  as  a  last  resource  an  opening  may  be  made 
into  the  bladder  through  the  anterior  vaginal  wall  and  the  urine 
allowed  to  constantly  flow  away  until  the  condition  is  relieved. 

Describe  the  operation  for  buttonholing  the  bladder  (colpocyst- 
otomy). 

The  patient  is  anresthetized  and  placed  in  the  Sims  position. 
A  Sims  speculum  is  introduced  and  a  sound  passed  into  the  blad- 
der. At  the  most  prominent  point  in  the  median  line  between 
the  neck  of  the  bladder  and  the  urethra  an  incision  is  made  longi- 
tudinally an  inch  long,  care  being  taken  to  cut  through  the  bladder 
mucous  membrane  as  much  as  the  vagina.  This  enters  about  half 
way  in  the  trigone  vesicae.  Now  with  a  sharply-curved  needle  and 
small  catgut  the  mucous  membrane  of  the  bladder  is  sutured  to 
that  of  the  vagina  to  prevent  healing.  Instead  of  these  sutures  a 
sigmoid  glass  tube,  provided  with  a  flange  at  one  end,  may  be  but- 
toned through  this  opening  and  allowed  to  remain.  It  is  usually 
necessary  to  keep  the  fistula  open  from  three  to  six  months.  The 
bladder  in  the  mean  time  is  frequently  irrigated  and  treated.  This 
operation  gives  great  relief  in  severe  chronic  cases.  The  opening 
is  finally  closed  as  any  other  fistula. 

What  are  the  varieties  of  fistulse  of  the  genital  tract  ? 

The  uterus  and  vagina  may  be  connected  by  one  or  more  aper- 
tures of  variable  size  and  shape  with  some  viscus  in  immediate 
proximity,  such  as  the  bladder,  rectum,  peritoneum,  etc.  They  are 
named  according  to  the  parts  connected  : 

Vesico-vaginal  fistula  (2  and  8,  Fig.  80). 


FISTULA. 


81 


Vesico-uterine  fistula  (1,  Fig.  30). 
Urethro-vaginal  fistula  (4,  Fig.  30). 


Fig.  30. 


Xocation  of  Various  Forms  of  Fistula :  1 ,  vesico-uterine  fistula ;  2,  vesico-utero-vaginal 
fistula;  3,  vesico-vaginal  fistula;  4,  urethro-vaginal  fistula;  5,  recto-vaginal  fistula; 
6,  recto-labial  fistula ;  7,  fistula  in  auo. 

Recto-vaginal  fistula. 
Entero-vaginal  fistula. 
Peritoneo-vaginal  fistula. 

Give  the  etiology,  diagnosis,  and  treatment  of  fistula. 

Etiology. — The  majority  of  the  cases  of  fistula  result  from  pres- 
sure of  the  child's  head  during  parturition,  causing  a  slough ;  but 
rarely  they  have  their  origin  in  abscesses,  stone  in  the  bladder, 
pessaries,  cancerous  and  syphilitic  ulcerations. 

Diagnosis. — Continuous  escape  of  urine  from  the  vagina,  causing 
vaginitis  and  vulvitis,  and  the  strong  urinous  odor  will  indicate 
urinary  fistula.  Escaped  faeces  into  the  vagina  will  show  a  rectal 
fistula.  If  the  opening  is  large,  it  can  readily  be  felt  with  the 
finger.  If  too  small  to  be  seen  or  felt,  milk  may  be  injected  into 
6— Gyn, 


82 


THE  URETHRA  AND  BLADDER. 


the  bladder,  which  is  seen  to  escape  from  the  fistula,  and  indicates 
the  site. 

Describe  Sims's  operation  for  vesico-vaginal  and  ure  thro -vaginal 
fistula. 

Treatment. —  Operative. — The  patient  having  been  prepared  for 
operation  as  in  perineal  operations,  she  is  anaesthetized  and  placed 
in  Sims's  position.  A  Sims  speculum  is  introduced  and  the  ante- 
rior vaginal  wall  and  fistula  are  exposed.     The  edges  of  the  fistula 

Fig.  31. 


Operation  for  Vesico-vaginal  Fistula. 

are  now  pared,  care  being  taken  not  to  injure  the  mucous  mem- 
brane of  the  bladder.  The  wound  thus  formed  will  be  bevelled 
from  the  bladder  out.  The  sutures  are  of  fine  silver  wire  threaded 
on  carrying  threads,  and  passed  with  small  curved  needles.  The 
needle  enters  first  at  the  most  accessible  angle,  half  an  inch  from 


VESICO-VAGINAL   FISTULA. 


83 


the  edge  of  the  denudation  ;  it  is  brought  out  at  the  vesical  sur- 
face, but  not  involving  the  mucous  membrane,  counter-pressure 
being  exerted  with  a  hook  or  tenaculum.  The  wire  is  now  drawn 
through,  and  the  point  of  the  needle  reintroduced  into  the  other 
lip  and  drawn  out  half  an  inch  from  the  edge  of  the  incisions.  In 
this  manner  a  sufficient  number  of  sutures,  one-fifth  of  an  inch 
apart,  are  introduced  and  twisted  with  wire-twisters.     A  self-retain- 

FiG.  32. 


Simon's  Position  for  Operation  on  Yesico-vaginal  Fistula. 

ing  sigmoid  catheter  is  now  introduced  into  the  urethra,  through 
which  the  urine  constantly  drains  until  the  wound  has  healed. 
The  sutures  may  be  removed  in  eight  or  nine  days. 

What  modification  of  this  operation  may  be  used  with  advan- 
tage ? 

Simon's    operation.      This    consists    in    placing    the    patient    in 


84  DISEASES   OF   THE   UTERUS. 

Simon's  position — i.  e.  an  exaggerated  lithotomy  position,  the  pelvis 
elevated.  The  cervix  is  grasped  and  drawn  down  as  for  a  Martin's 
anterior  colporrhaphy,  and  the  field  of  operation  thus  well  exposed. 
The  edges  are  pared  as  before  with  scissors  or  knife,  and  sutures 
passed,  which  in  this  case  are  of  silk. 

What  is  the  treatment  for  vesico-uterine  fistula? 

Split  up  the  anterior  lip  of  the  cervix  to  the  fistula,  freshen  its 
edges,  and  pass  sutures  through  the  cervix  so  as  to  unite  the  walls 
of  the  cervix  and  lips  of  the  fistula.  When  the  fistular  opening  is 
too  high  up  for  this  operation,  the  cervix  may  be  closed  entirely 
and  the  uterine  contents  allowed  to  discharge  through  the  bladder. 

What  is  the  treatment  for  recto-vaginal  fistula  ? 

The  edges  may  be  pared  and  brought  together  as  in  the  opera- 
tion for  vesico-vaginal  fistula.  If  the  opening  is  near  the  vulva, 
the  tissues  between  it  and  the  surface  may  be  split  and  the  edges 
of  the  fistula  dissected  out,  and  the  whole  united,  as  in  laceration 
of  the  perineum,  through  the  sphincter. 

THE   INTERNAL   ORGANS   OF   GENERATION. 
DISEASES  OF  THE  UTERUS. 

ANATOMY. 
Describe  the  uterus. 

The  uterus  is  a  hollow  muscular,  pear-shaped  organ,  situated  in 
the  centre  of  the  pelvis  between  the  bladder  and  rectum.  It  meas- 
ures 3  inches  in  length,  2  in  breadth  at  the  level  of  the  Fallopian 
tubes,  and  1  inch  in  thickness.  It  lies  normally,  when  the  bladder 
and  rectum  are  empty,  in  a  position  of  anteversion  and  slight  ante- 
flexion. The  cervical  os  points  downward  and  backward,  but  its 
position  is  constantly  changing,  owing  to  distension  of  the  bladder 
and  rectum. 

It  is  divided  into  a  body,  neck,  and  fundus.  The  fundus  is  that 
portion  above  the  entrance  of  the  Fallopian  tubes ;  the  body  is  the 
portion  between  the  fundus  and  the  neck  ;  the  neck  is  the  lower 
half  of  the  uterus,  its  junction  with  the  body  being  marked  by  a 
slight  depression  or  sulcus  called  the  isthmus.  The  cavity  of  the 
body  is  triangular  in  shape,  the  anterior  and  posterior  walls  being 
in  contact.     It  has  a  capacity  of  about  twelve  drops  in  nullipar.ie. 


ANATOMY.  85 

The  cavity  of  the  cervix  is  spindle-shaped,  being  constricted  at 
the  internal  and  external  os. 

The  cervix  is  divided  into  two  portions  anatomically — that  above 
the  attachment  of  the  vagina  (supravaginal),  and  that  below  the 
attachment,  protruding  into  the  vagina  (vaginal).  Schroeder  makes 
a  third  division,  an  intermediary  portion,  below  the  vaginal  junc- 
tion behind,  and  above  it  in  front.  The  vaginal  portion  varies 
much  in  shape  and  size.  At  its  centre  is  the  external  os,  which  in 
virgins  is  slit-shaped,  feeling  something  like  the  cartilage  at  the 
end  of  the  nose.  The  entire  cavity  of  the  uterus  measures  2^ 
inches  in  length. 

The  uterine  wall  consists  of  three  layers :  (1)  internal  mucous 
membrane  ;  (2)  middle  muscular  ;  (3)  external  peritoneal. 

The  mucous  membrane  of  the  body  diifers  from  that  of  the 
cervix.  It  is  smooth,  grayish-pink  in  color,  and  directly  connected 
to  the  muscular  layer,  without  the  intervention  of  a  submucous 
coat.  It  consists  of  a  single  layer  of  columnar  ciliated  epithelial 
cells,  the  cilia  moving  upward.  These  rest  on  a  connective-tissue 
base,  which  is  rich  in  lymph-spaces,  vessels,  and  nerves.  Imbedded 
in  its  substance  are  a  large  number  of  tubular  glands,  the  utricular 
follicles,  which  may  be  straight,  tortuous,  single,  or  branching,  and 
have  their  blind  extremities  terminating  in  the  muscular  coat. 
They  are  lined  with  a  single  layer  of  prismatic  ciliated  cells  resting 
on  a  membrana  propria,  and  they  secrete  an  alkaline  mucus. 

The  mucous  membrane  of  the  cervix  is  thicker  and  less  red  than 
that  of  the  body.  It  is  thrown  into  numerous  folds  called  the 
"  arbor  vitae,"  which  consist  of  an  anterior  and  posterior  ridge, 
from  which  lateral  folds  branch  off.  The  surface  is  covered  by  a 
single  layer  of  epithelial  cells,  which  are  ciliated  on  the  ridges  and 
non-ciliated  in  the  depressions  (De  Sinety). 

The  cervical  glands  are  racemose,  and  secrete  a  clear  alkaline 
mucus.  When  these  become  pathologically  occluded,  they  produce 
the  retention  cysts  known  as  the  follicles  or  ovula  of  Naboth.  The 
mucous  membrane  covering  the  vaginal  portion  is  continuous  with 
that  of  the  vagina,  and  consists  of  vascular  papillae  covered  with 
many  layers  of  squamous  epithelium.  There  is  a  sharp  line  of 
demarcation  between  this  latter  and  the  columnar  ciliated  epithe- 
lium of  the  cervical  canal. 

The  vaginal  aspect  has  no  glands.  The  muscular  coat  consists 
of  three  layers  of  unstriped  fibres  :  (1)  External,  a  thin  longitu- 
dinal layer  called  the  platysma,  most  marked  on  the  anterior  and 


86 


DISEASES   OF   THE   UTERUS. 


posterior  walls,  which  sends  prolongations  into  the  ligaments  of  the 
uterus  and  out  to  the  Fallopian  tubes.  (2)  Middle  is  the  thickest, 
and  consists  of  longitudinal,  transverse,  and  oblique  fibres.  (3) 
Internal,  concentric  and  most  marked  about  the  orifices  of  the  Fal- 
lopian tubes  and  internal  os. 

The  peritoneal  coat  folds  over  the  entire  posterior  surface  of  the 
uterus,  except  the  vaginal  portion  of  the  cervix.  It  covers  the 
anterior  surface  as  low  as  the  isthmus,  and  is  here  reflected  on  to 
the  bladder.  Laterally,  the  two  folds  come  together,  forming  the 
broad  ligaments,  and  extend  to  the  wall  of  the  pelvis.  Anteriorly 
it  is  firmly  connected  to  the  uterine  wall ;  posteriorly  a  layer  of 
areolar  tissue  is  interposed.     It  is  composed  of  a  base  of  fibrous 

Fig.  33. 


Position  of  Parts  in  Female  Pelvis. 


and  clastic  tissues  covered  by  a  layer  of  endothelial  cells,  and  is 
very  rich  in  lymphatics. 


ANATOMY.  87 

Name  and  describe  the  ligaments  of  the  uterus. 

Two  broad  ligaments  ;  two  round  ligaments  ;  two  utero-vesical ; 
two  utero-sacral. 

The  broad  ligaments  are  double  folds  of  peritoneum  which  run 
from  the  sides  of  the  uterus  to  the  pelvic  wall.  Internally  they  are 
continuous  with  the  peritoneum  covering  the  anterior  and  posterior 
walls.  Externally  they  are  attached  to  the  pelvic  wall  "  along  a 
line  situated  between  the  great  sacro-sciatic  notch  and  the  margin 
of  the  obturator  foramen,  as  far  down  as  the  level  of  the  ischial 
spine."  Their  upper  free  margin  contains  the  Fallopian  tubes. 
The  portion  of  the  margin  not  occupied  by  the  tube,  and  extend- 
ing from  it  to  the  pelvic  wall,  is  called  the  infundibulo-pelvic  liga- 
ment. 

The  ovary  projects  through  the  posterior  lamella,  and  is  covered 
by  germinal  epithelium.  It  is  attached  at  its  hilum  to  the  anterior 
lamella. 

The  round  ligaments  lie  in  a  fold  formed  by  the  anterior  lamella. 

The  portion  of  broad  ligaments  extending  between  the  ovary  and 
the  Fallopian  tube  is  called  the  mesosalpinx.  In  the  mesosalpinx 
below  the  middle  of  the  tube  is  the  parovarium. 

The  structures  included  between  the  folds  of  the  broad  ligament 
are,  from  above  downward,  (1)  the  Fallopian  tube ;  (2)  ovarian 
artery,  nerves,  and  lymphatics ;  (3)  the  pampiniform  plexus  of 
veins ;  (4)  the  round  ligament ;  (5)  the  parovarium  ;  (6)  the  ova- 
rian ligament ;  (7)  the  ovary  ;  (8)  the  uterine  artery  and  venous 
plexus ;  (9)  connective  tissue  and  lymphatics  near  the  base. 

The  round  ligaments  spring  from  the  anterior  superior  portion  of 
the  uterus,  and  extend  outward  and  forward  in  the  anterior  folds 
of  the  broad  ligaments  to  the  internal  inguinal  rings.  They  then 
pass  through  the  inguinal  canal  and  terminate  in  three  fasciculi. 

The  inner  fasciculus  blends  with  the  tendons  of  the  internal 
oblique  and  transversalis  muscles ;  the  middle  with  the  superior 
column  of  the  external  abdominal  ring  ;  and  the  external  terminates 
just  above  Gimbernat's  ligament.  They  are  composed  of  fibrous 
tissue,  striped  and  unstriped  muscular  fibres,  and  blood-vessels  and 
nerves. 

The  peritoneal  investment  of  the  round  ligaments  usually  ends 
at  the  internal  ring,  but  is  sometimes  prolonged  into  the  labia 
majora.  This,  when  pervious,  is  called  the  "  canal  of  Nuck." 
The  chief  interest  attaching  to  the  round  ligaments  is  their  con- 
nection with  Alexander's  operation. 


88  DISEASES    OF    THE    UTERUS. 

The  utero-sacral  ligaments  are  two  folds  of  peritoneum  reflected 

Fig.  34. 


Diagram  showing  the  Three  Minor  Folds  of  the  Broad  Ligament  (Ranney) :  1,  2,  3,  ante- 
rior, middle,  and  posterior  folds;  A',  round  ligament;  /<',  Fallopian  tube ;  O,  ovary ;  K, 
vagina;  h,  pouch  of  Douglas;  A,  anterior  layer  of  broad  ligament;  P,  posterior  layer; 
£,  reflection  of  peritoneum  to  bladder;  i?,  reflection  to  rectum  •  (S,  space  containing 
muscular  and  connective  tissue,  enclosing  vessels  and  nerves. 

from  the  sides  of  the  uterus  at  the  level  of  the  isthmus  backward, 
outward,  and  upward  to  the  second  sacral  vertebra.     They  form 


ANATOMY. 


89 


the  upper  lateral  boundaries  of  the  pouch  of  Douglas,  and  are  of 
great  importance  in  some  malpositions  of  the  uterus. 

The  utero-vesical  ligaments  are  the  folds  of  peritoneum  reflected 
from  the  lower  portion  of  the  uterus  on  to  the  bladder. 

What  is  the  vascular  supply  of  the  uterus  ? 

Arterial:   From  the  uterine  and  ovarian  arteries.     The  uterine 
branch  of  the  internal  iliac  runs  along  the  base  of  the  broad  ligament 

Fig.  35. 


Ovarian  /Jrtery 


Uterine  Hrtery 


The  Ovarian,  Uterine,  and  Vaginal  Arteries  (Hyrtl) :  n,  ovarian  artery ;  a'  and  6'» 
branches  to  tube;  6,  branch  to  round  ligament;  c',  branches  to  ovary;  g,  vaginal 
artery ;  /«,  azygos  artery  of  vagina. 

to  a  point  below  the  level  of  the  os  externum  near  the  cervix  ;  then 
it  curves  upward  along  the  uterine  wall  and  anastomoses  with  the 
ovarian.  Its  branches  in  the  substance  of  the  uterus  are  very 
tortuous,  and  are  known  as  the  "  curling  arteries."  At  the  junc- 
tion of  the  body  with  the  cervix  a  large  branch  is  given  off  which 
unites  with  its  fellow  of  the  opposite  side  to  form  the  "  circular 
artery." 

The  veins,  form  a  plexus  around  the  uterus  beneath  the  peri- 
toneum, and  communicate  with  the  vaginal  and  vesical  plexuses 
below  and  the  pampiniform  above.  They  empty  into  the  internal 
iliac  vein. 


90 


DISEASES    OF   THE    UTERUS. 


The  lymphatics  are  very  numerous,  and  form  a  dense  network  in 
the  broad  ligaments,  terminating  in  the  lumbar  and  hypogastric 
glands. 

The  nerve-supply  is  derived  from  the  hypogastric  plexus  of  the 
sympathetic,  and  a  few  fibres  from  the  third  and  fourth  sacral 
nerves. 

MALFORMATIONS   AND   DISEASES   OF   THE  UTERUS. 

Malformations. 
It  is  of  the  greatest  importance,  in  the  study  of  malformations 
of  the  uterus,  to  bear  in  mind  the  mode  of  development  of  the 
genital  tract. 

Give  a  brief  description  of  the  development  of  the  female  genitals, 
and  state  how  malformations  of  the  uterus  are  produced. 

Before  the  end  of  the  second  month  of  foetal  life  the  Wolffian 


Fig  36. 


uterus  Bipartitus  of  a  servant  sixty  years  of  age:  «,  vagina,  about  one  inch  deep,  and 
ending  at  the  anterior  wall  of  the  rectum,  above  the  internal  sphincter;  b,  connec- 
tive tissue  interspersed  with  muscular  fibres,  simulating  the  shape  of  a  uterus;  c.  c, 
fleshy  strings  representing  the  horns  of  the  uterus  ;  (/,  (/,  swellings  of  the  size  of  a 
bean,  one  cui  open  and  showing  a  cavity  of  tlie  size  of  a  lentil  and  lined  with  mucous 
membrane;  e,e,  rudimentary  ovaries; /,/,  Falloi)iau  tubes;  g,  round  ligaments;  h, 
broad  ligaments.     (From  Kussmaul,  after  Mayer.) 

bodies  appear,  one  on  either  side  of  the  vertebral  column.     Kach 


MAI.FOR^rATIONS. 


91 


consists  of  a  large  number  of  convoluted  tubules  closed  at  one 
end,  and  opening  by  the  other  into  a  common  duct.  In  a 
fissure  at  the  inner  border  of  these  bodies  lies  the  genital  gland  on 
each  side,  which  subsequently  develops  into  the  ovary.  The  ducts 
of  Miiller  spring  from  the  inner  sides  of  the  upper  ends  of  the 
Wolffian  bodies,  one  on  each  side.  These  approach  each  other,  and 
coalesce  to  form  the  uterus  and  vagina,  the  septum  being  absorbed. 
The  upper  portion  of  the  ducts  forms  the  Fallopian  tubes. 

Malformations  are  produced  when  there  is  an  arrest  of  develop- 
ment in  one  or  both  of  the  ducts  of  Miiller ;  when  they  fail  to 
unite ;  when  the  septum  between  them  is  not  absorbed. 

What  are  the  varieties  of  malformations  ? 

(1)  Absence  of,  or  a  rudimentary,  uterus,  occurring  when  there  is 
an  arrest  of  development  of  the  ducts  of  Miiller.     This  condition  is 


Fig.  37. 


uterus  Bicornis  Unicollis  of  a  Virgin ;  a,  vagina  ;  6,  single  neck  ;  c,  c,  horns  ;  (f,  d,  tubes  ; 
e,  e,  ovaries; /,/,  round  ligaments.    (From  Kussmaul.) 

usually  accompanied   by  absence  of  the  entire  generative  tract. 

(2)  Unicorn  uterus,  due  to  an  arrest  in  the  development  of  one 
duct  of  Miiller. 

(3)  Uterus  bicornis,  where  the  union  of  the  Miillerian  ducts  is 
imperfect,  resulting  in  two  horns. 


92 


DISEASES   OF   THE    UTERUS. 
Fig.  38. 


Uterus  Unicornis:  LH,  left  horn;  /vT,  left  tube;  Xo,  left  ovary;  Z/Z,-,  left  round  liga- 
ment ;  Rll,  right  horn ;  RT,  right  tube ;  Ro,  right  ovary ;  RLr,  right  round  liga- 
ment.   (From  Schroeder.) 

(4)  Double  uterus  (very  rare),  in  which  the  two  horns  have  de- 

FiG.  39. 


uterus  Didelphys:  o,  right  cavity;  h,  left  cavity  ;  c,  right  ovary;  d,  right  round  liga- 
ment; e,  left  round  ligament ;/,  left  tube;  f/,  left  vaginal  portion;  //,  right  vaginal 
portion  ;  /,  right  vagina;  j,  left  vagiua  ;  k,  partition  between  the  two  vaginae.  (From 
De  iSinety,  after  Ollivier.) 


MA  LFORM  ATIONS. 

Fig.  40. 


93 


Uterus  Bicornis  Duplex :  «,  double  entrance  to  vagina;  6,  meatus  urinarius  ;  c,  clitoris  ; 
d,  urethra  ;  e,  e,  double  vagina ;  /,  /,  external  orifices  of  uterus ;  g,  g,  double  cervix ;  h 
h,  bodies  and  horns  of  uterus;  i,  t,  ovaries;  f:,  k,  tubes;  I,  I,  round  ligaments;  m,  jn, 
broad  ligaments.    (From  Kussmaul,  after  Eisenmann.) 

veloped  separately,  not  coalescing.     This  is  usually  associated  with 
a  double  vagina. 

(5)  Divided  uterus,  in  which  the  septum  has  not  been  absorbed. 


94 


DISEASES   OF   THE   UTERUS. 


(G)   Foetal    or   infantile    uterus,    in    which    the    uterus   remains 
small,  and  there  is  a  disproportionately  large  neck.     At  birth  the 


Fig.  41. 


UtfTus  .Septus  Duplex  (natural  size),  completely  double  uterus  and  incompletely  double 
vagina  of  a  girl  twenty-two  years  old  :  n,  a,  tubes  ;  h,  b,  fundus  of  the  double  uterus; 
c,  <;,  c,  partition  of  uterus  ;  d,  d,  cavities  of  the  uterine  bodies;  e,  e,  internal  orifices; 
f,  f,  external  walls  of  the  two  necks;  {/,  (/,  external  orifices;  h,  h,  vagrnal  canals  ;  i, 
"partition  which  divided  the  upper  third  of  the  vagina  into  two  halves.  (From  Kuss- 
maul.) 

neck  is  normally  small,  larger  than  the  body,  and  if  arrest  of  de- 
velopment takes  place  at  this  stage  the  above  condition  results. 

(7)  Congenital  atrophy.  This  condition  results  from  a  lack  of 
development  after  the  uterus  has  reached  its  normal  proportions, 
remaining  small. 


MALFORMATIONS. 


95 


Fk4.  43. 


Infantile  Uterus  of  a  girl  twenty-one  years  old  :  A,  uterus  and  appendages  diminished  : 
a,  body;  A;,  neck;  c,  c,  tubes;  rf,  rf,  ovaries ;  e,  e,  round  ligaments;/,  /,  broad  liga- 
ments; ^,  right  ovary  cut  open  longitudinally,  showing  large  Graafian  follicles;  C, 
left  ovary  with  smaller  follicles.     (From  Kussmaul.) 

HYPERTROPHY. 
In  what  sites  may  hypertropliy  of  the  cervix  occur  ? 

In  the  supravaginal  portion,  the  median 
portion,  or  the  infra  vaginal  portion  of  the 
cervix.  Hypertrophy  of  the  infravaginal 
portion  alone  requires  extended  description. 
It  is  seen  in  its  purest  type  in  unmarried 
women,  and  is  spoken  of  as  the  penis-like 
hypertrophy  of  the  cervix. 

What  is  its  pathology? 

The  histological  elements  are  uniformly 
increased  (especially  in  their  length).  The 
mucous  membrane  covers  a  more  extensive 
surface,  but  is  not  diseased.  As  the  in- 
fravaginal portion  increases  in  length,  it 
tends  to  become  conical.     The  external  os 

is  usually  small  and  at  the  apex.       The  cer-      Classification    of  the  Cervix 

vix  is  tense  and  firm  ;  it  presents  none  of        jroneum  ;%a 'biadfer?!;; 
the  sicjns  of  inflammation.    It  may  protrude        portio  vaginalis ;  ^,  portio 

n  "ii  1  1      1  •        Ti  i  •  media;  C.  portio  supravag- 

trom  the  vulva,  lookmg  hke  an  erect  penis.        inaiis.    (After  ^chroeder.) 


96 


DISEASES  OF   THE   UTERUS. 


What  are  its  symptoms? 

(1)  Dysmenorrhoea ;  (2)  disturbance  of  coitus ;  sterility ;  (3) 
symptoms  due  to  mechanical  irritation  if  it  protrudes  from  the 
vulva.     There  is  no  great  degree  of  dragging  pain. 

From  what  conditions  must  it  be  diagnosed,  and  how  ? 

From  prolapse  and  from  inversion  of  the  uterus.  In  hypertro- 
phy of  the  cervix  a  bimanual  examination  shows  the  existence  of 
the  body  of  the  uterus  and  of  the  anterior  and  posterior  fornices 
of  the  vagina,  all  in  their  normal  positions. 

What  is  the  treatment  ? 

The  only  treatment  of  any  effect  is  surgical — viz.  amputation  of 
the  cervix — 

(a)  By  the  galvano-cautery,  a  poor  method ; 
(h)  Schroeder's  operation,  a  wedge-shaped  excision  of  anterior 

and  posterior  lips,  followed  by  suture 
Fig.  44.  of 

membrane 


the   vaginal   and    uterine   mucous 


What  is  its  prognosis? 

Spontaneous  cure  does  not  take 
place.  The  prognosis  after  operation 
is  very  good  indeed.  The  removal  of 
even  a  small  portion  often  causes  in- 
volution of  the  rest. 

ATROPHY. 

What  are  the  two  varieties  of  acquired 
atrophy  of  the  uterus  ? 

(1)  Senile  atrophy  ;  (2)  premature 
atrophy. 

Describe  senile  atrophy  of  the  uterus. 
The  uterine  walls  are  thin  and  atro- 
phic ;  the  mucous  membrane  thin  and 
without  glands  ;  the  os  internum  is  often 
constricted,  and  sometimes  there  is  re- 
tention of  secretions.  The  vaginal  portion  of  the  cervix  is  oblite- 
rated, and  the  os  externum  is  felt  as  a  dimple.  The  vagina  is  short 
and  narrow  ;  its  walls  are  thin  and  membranous,  and  there  is  no 
fat  in    the   surrounding  tissues.     The  labia  majora  lie  far  apart. 


Schroeder's  Operation. 


DISPLACEMENTS   OF   THE   UTERUS.  97 

The  nymphae  are  almost  obliterated.  The  clitoris  is  small,  and  has 
neither  prepuce  nor  frgenulum.  The  condition  is  normal  after  about 
the  sixtieth  year,  and  gives  rise  to  no  symptoms  and  requires  no 
treatment. 

What  are  the  causes  of  premature  atrophy  of  the  uterus  ? 

It  occurs  usually  between  the  ages  of  twenty  and  forty-five 
years,  (a)  Puerperal  fever,  especially  if  the  ovaries  or  the  peri- 
toneum is  involved ;  (6)  tuberculosis ;  (c)  perhaps  sometimes 
removal  of  ovaries. 

What  are  the  symptoms? 

The  involution  is  abnormal,  leaving  the  uterus  soft  and  flabby, 
and  of  less  than  the  normal  size,  (a)  Anaemia  and  debility  ;  (6) 
amenorrhoea  after  confinement,  e-ven  after  stopping  lactation :  in 
fact,  most  of  these  patients  do  not  nurse  their  children  ;  (c)  change 
in    general    appearance    (prematurely   old,   distressed,  and    sick); 

(d)  hot  and  cold  flashes,  and  rushing  of  blood  to  the  head  or  face  ; 

(e)  disturbed  vision ;  (/)  cold  hands  and  feet;  (^)  hysterical  fits 
of  crying,  etc. 

Upon  what  is  the  diagnosis  based? 

Absence  of  menstruation  ;  uterus  small,  thin,  and  flabby  ;  with 
the  probe  in  the  uterine  cavity  the  uterus  feels  thin,  and  not  firm. 
The  cavity  measures  about  two  inches,  but  may  measure  two  and 
a  half  inches. 

What  is  the  treatment  ? 

(a)  General :  Change  of  climate,  exercise,  diet,  attention  to  func- 
tions of  the  skin  and  digestive  tracts. 

(h)  Local:  Irritation;  occasional  use  of  the  sound;  occasional 
use  of  tents  (cautiously)  ;  the  galvanic  pessary. 

What  is  the  prognosis  ? 

The  disease  does  not  threaten  life.  A  return  to  the  normal  con- 
dition is  exceptional,  but  the  unpleasant  symptoms  may  often  be 
ameliorated. 

DISPLACEMENTS   OF   THE  UTERUS. 

Describe  the  normal  position  of  the  uterus  in  the  living  woman, 
and  the  factors  which  influence  it. 

"  The  normal  position  of  the  uterus  is  determined  by  its  con- 
nection with  the  tissues  adjacent  to  it,  by  its  fixation  in  the  vagina 

7-Gyn. 


98 


DISEASES   OF   THE   UTERUS. 


and  pelvic  fascia,  and  by  its  attachment  to  the  bladder  and  to  the 
peritoneum  "  (Shultze). 

The  muscular  fibres  in  the  round  ligaments  and  in  the  folds  of 
Douglas    are  important  factors,  the  former   drawing  the    fundus 


Fig.  45. 


Horizontal  Section  of  Body,  showing  uterus  and  round  ligaments  (Savage) :  B,  bladder ; 
U,  uterus ;  C  C,  utero-sacral  ligaments ;  L  L,  round  ligaments ;  0  O,  ovaries ;  T  T, 
tubes ;  iJ,  rectum. 


forward,  and  the  latter  drawing  the  cervix  backward.  Intra-ab- 
dominal pressure  and  its  own  weight  also  influence  the  position  of 
the  uterus,  the  former  much  more  than  the  latter  during  life. 

The  uterus  is  capable  of  considerable  mobility,  being  pushed 
backward  by  a  distended  bladder  (Fig.  47),  forward  by  a  distend- 
ed rectum  (Fig.  48),  and  upward  when  both  are  full  (Fig.  49). 
Bimanual  examination  and  the  uterine  sound  are  the  methods  em- 
ployed in  determining  the  position  of  the  uterus. 

"  When  a  woman  is  standing  upright,  and  her  rectum  and 
bladder  are  empty,  her  uterus  is  nearly  horizontal,  is  more  or  less 


Fig.  46. — Position  of  the  Uterus  in  a  Frozen  Section  when  the  Rectum  and  Bladder 
are  Empty  (Martin).    Differing  from  the  representations  usually  given. 


Fig.  47.— Uterus  pushed  Backward  by  a  Distended  Bladder  (Martin). 

99 


Fig.  48.— Uterus  pushed  Forward  by  a  Distended  Rectum  (Martin). 


Fig.  4'J.— Position  of  Uterus  in  a  Frozen  Section  when  both  the  Bladder  and  Rectum  are 

Distended  (Martin). 

100 


DISPLACEMENTS    OF   THE    UTERUS. 


101 


anteflexecl,  and  is  turned  a  little  to  the  right"  (Shiiltze).  (See 
Fig.  50.)  In  the  dorso-horizontal  position  of  the  woman  the  fundus 
uteri  lies  behind  and  a  little  above  the  symphysis,  the  os  uteri 
faces  the  rectum,  and  the  cervix  makes  nearly  a  right  angle  with 
the  vagina.  When  the  bladder  is  empty  its  superior  and  inferior 
walls  come  in  contact,  and  the  fundus  uteri  lies  forward  on  these, 

Fig.  50. 


Normal  Position  of  the  Uterus  during  life  when  the  bladder  and  rectum  are  empty. 


as    shown  in    Fig.  50.      This  is   determined  by  the   use    of  the 
sound  in  the  bladder  and  bimanual  examination. 

The  uterus  is  normally  much  more  flexible  than  is  usually  sup- 
posed, being  easily  bent  at  the  junction  of  the  body  with  cervix 
(i.  e.,  the  os  internum)  by  the  fingers  during  bimanual  examina- 
tion.    After  death  this  flexibility  ceases. 


102  DISEASES   OF   THE   UTERUS. 

Define  what  is  understood  by  pathological  displacements  of  the 
uterus,  and  state  the  varieties. 

Any  variation  from  the  normal  position  of  the  uterus  which 
is  permanent  constitutes  a  displacement.  Abnormal  mobility  or 
fixation  is  also  looked  upon  as  a  displacement,  which  is  classified 
accordino;  to  the  direction  from  the  normal. 

The  varieties  are — elevation,  descent,  prolapse,  anteposition, 
retroposition,  latero-position,  anteversion,  retroversion,  anteflexion, 
retroflexion,  latero-flexion. 

The  uterus  may  be  twisted  about  its  long  axis,  constituting 
torsion. 

Combinations  may  exist  of  retroversion  with  anteflexion,  ante- 
version  with  retroflexion,  etc. 

What  is  the  frequency  of  uterine  displacements  ? 

They  are  among  the  most  common  afi"ections  of  the  female 
generative  organs. 

What  is  meant  by  flexions,  and  what  by  versions  of  the  uterus  ? 

Flexion  of  the  uterus  signifies  a  bending  of  the  uterine  body  at 
its  junction  with  the  cervix  (the  internal  os),  and  is  in  the  majority 
of  cases  only  an  expression  of  the  normal  flexibility  of  the  uterus. 
By  version  is  meant  an  inclination  of  the  whole  uterus  without 
flexion,  the  canal  being  straight,  and  it  is  due  to  rigidity  and  loss 
of  the  normal  flexibility.  Therefore  versions,  either  retro-  or  ante-, 
are  more  serious  than  flexions. 

Flexions  are  always  associated  with  more  or  less  version,  but 
version  presupposes  the  absence  of  flexion. 

ANTEVERSION. 

What  are  the  etiology  and  pathology? 

Pathological  anteversion  is  that  position  of  the  uterus  in  which 
the  fundus  lies  forward  on  the  bladder,  with  its  axis  straightened 
out  and  the  cervix  pointing  backward  to  the  hollow  of  the  sacrum, 
the  whole  uterus  less  than  normally  movable  and  rigid.  This  is 
due  to  inflammatory  thickening  and  infiltration,  destroying  the 
normal  flexibility  of  the  uterus.  It  is  always  associated  with  peri- 
or  parametritis  and  metritis,  the  former  forcing  the  cervix  back- 
ward and  above  'and  the  fundus  below,  and  the  metritis  causing 
a  general  enlargement  of  the  uterus  and  thickening,  chiefly  at  the 
junction  of  the  body  with  the  cervix. 


DISPLACEMENTS   OF   THE    UTERUS. 


103 


The  causes  are  those  which  produce  para-  and  perimetritis  and 
cellulitis  :  subinvolution,  lacerations  of  the  cervix,  sepsis,  and  other 


Fig.  51. 


Normal  Position  of  the  Uterus  in  a  Parous  Woman  (Scbultze). 

acute    and    chronic   inflammations    affecting    the   peritoneum    and 
uterus. 


What  are  the  symptoms? 

The  symptoms  are  those  of  the  accompanying  perimetritis  and 
metritis  ;  also  frequent  micturition,  due  to  pressure  of  the  fundus 
on  the  bladder  and  thus  preventive  of  its  proper  expansion. 

The  movements  of  the  heavy  tender  uterus  due  to  varying  ful- 
ness of  the  bladder  and  the  postural  changes  of  the  back  cause 
discomfort  and  metrorrhagia. 


104  DISEASES    OF   THE    UTERUS. 

What  is  the  diagnosis? 

This  is  made  by  bimanual  examination.  The  fundus  lies  forward 
on  the  anterior  vaginal  wall,  the  cervix  points  backward  and  up- 
ward into  the  hollow  of  the  sacrum,  and  there  is  complete  absence 
of  flexion. 

What  is  the  treatment? 

This  is  directed  to  the  cure  of  the  metritis  and  pelvic  peritonitis 
by  hot  douches,  iodine  to  the  cervix  and  fornices,  and  boroglycerite 
tampons.  After  the  inflammatory  conditions  have  been  removed,  a 
soft  rubber  ring  or  a  Graily-Hewitt's  cradle  pessary  may  be  ad- 
justed with  advantage.  Ergot  and  hydrastis  may  be  administered 
for  the  metrorrhagia.  Scarification  of  the  cervix  is  useful.  Schroe- 
der's  amputation  of  the  cervix  by  curing  the  metritis  relieves  all 
the  symptoms. 

ANTEFLEXIONS. 

What  are  the  etiology  and  pathology? 

Anteflexion  is  the  inclination  forward  of  the  body  of  the  uterus 
alone,  the  bend  nearly  always  taking  place  at  the  level  of  the  inter- 
nal OS.  It  is  an  exaggeration  of  the  normal  condition,  and  only 
becomes  pathological  when  there  is  rigidity  at  the  point  of  flexion. 

What  is  the  etiology? 

Anteflexion  may  be  congenital  (puerile,  in  which  there  is  the 
elongated  cervix)  or  acquired.  The  latter  is  due  to  causes  situated 
within  or  without  the  walls  of  the  uterus.  Causes  within  are — 
metritis,  fixing  the  point  of  flexion  ;  irregular  involution,  during 
which  the  posterior  wall  remains  large  ;  tumors  of  the  posterior 
wall  with  broad  bases.  Causes  from  without  are  the  most  common : 
parametritis  and  perimetritis,  followed  by  contractions  in  the  folds 
of  Douglas  and  utero-sacral  ligaments,  drawing  the  middle  segment 
of  the  uterus  upward  and  backward.  The  posterior  parametritis 
may  be  of  puerperal  origin  or  due  to  laceration  of  the  cervix,  cer- 
vical catarrh,  etc. 

What  are  the  symptoms  ? 

They  are  chiefly  those  of  the  causes,  especially  posterior  para- 
metritis. The  two  most  important  symptoms  are  dysmenorrhoea 
and  sterility.  Other  symptoms  are  frequent  and  painful  micturi- 
tion, pain  on  defecation,  leucorrhcjca,  backache. 


DISPLACEMENTS   OF    THE    UTERUS. 


105 


What  is  the  diagnosis  ? 

The  diagnosis  consists  in  the  establishment  of  the  stability  of 
the  flexion.  This  can  be  determined  by  bimanual  and  recto-abdomi- 
nal examination  and  the  use  of  the  sound.     Note  whether  the  flex- 

FiG.  52. 


Anteflexion  of  Uterus. 


ion  remains  with  a  distended  bladder  ;  note  a  thickening  contraction 
and  tenderness  in  the  folds  of  Douglas  and  utero-sacral  ligaments. 
On  digital  examination  the  cervix  is  found  lying  in  the  axis  of  the 
vagina,  rather  high,  os  pointing  forward,  and,  as  the  finger  is  passed 
along  the  anterior  wall,  a  sulcus  is  felt  at  the  junction  of  the  body 
with  the  cervix.     The  fundus  is  found  lying  forward. 


106  DISEASES   OF   THE   UTERUS. 

What  is  the  treatment? 

Except  for  those  cases  in  which  the  rigidity  is  due  to  tumors  of 
the  posterior  wall  and  to  metritis  the  treatment  consists  in  the  re- 
moval of  the  existing  posterior  parametritis.  This  is  done  by  the 
use  of  boroglycerite  and  depleting  tampons,  local  applications  of 
iodine  and  iodide-of-potash  solution  in  glycerin,  hot  vaginal  douches, 
and  sitz-baths.  Keep  the  bowels  well  regulated.  For  existing  en- 
dometritis the  cervical  canal  to  above  the  internal  os  may  be  dilated, 
and  the  endometrium  thoroughly  washed  out  with  carbolic  solution, 
1 :  100.  After  all  inflammatory  conditions  have  been  removed, 
the  uterine  cavity  may  be  dilated  with  Peaslee's  steel  dilators  and 
Goodell's  dilator,  and  an  intra-uterine  stem,  such  as  Outerbridge's 
wire  stem,  introduced.  This  stem  may  be  left  in  place  for  one 
month,  or  the  dilatation  may  be  maintained  by  passing  the  steel 
dilators  once  or  twice  a  month.  Chlorosis  is  a  frequent  complica- 
tion, and  must  be  treated. 

For  what  might  anteflexions  be  mistaken  ?  and  what  is  the  differ- 
ential diagnosis  ? 
Anteflexions  might  be  mistaken  for  a  fibroid  of  the  anterior  wall 
and  anterior  inflammatory  and   cellulitic  exudations.     The  sound 
passed  into  the  uterine  cavity  will  determine  these  conditions. 

RETROVERSION  AND  RETROFLEXION. 

Define  these. 

Ketroversion  is  the  stable  inclination  of  the  fundus  uteri  back- 
ward, the  shape  of  the  organ  being  extended  or  slightly  anteflexed 
(Shultze).  Retroflexion  is  the  stable  or  permanent  backward  dis- 
location of  the  fundus  uteri,  with  simultaneous  bending  of  the 
uterus  over  its  posterior  surface.  There  is  usually  first  a  version, 
then  a  flexion,  due  to  a  continuance  of  the  intra-abdominal  pressure 
acting  upon  the  anterior  aspect. 

What  are  the  etiology  and  anatomy? 

The  cause  may  be  acute  or  chronic.  Acute  (rare)  :  falls,  blows 
on  \\\Q,  abdomen,  lifting  heavy  weights,  all  of  these  accompanied  by 
the  condition  of  a  full  bladder. 

Chronic:  arrest  of  development,  resulting  in  a  long  cervix  and 
short  anterior  vaginal  wall.  The  dilatation  of  the  bladder  pushes 
the  uterus  back  into  retroversion.  If  metritis  is  present,  it  be- 
comes rigid  and  stable.  Senile  shortening  of  the  anterior  vaginal 
wall  also  produces  this  condition. 


DISPLACEMENTS   OF   THE   TJTEEUS. 


107 


Retroversions  and  flexions  are  more  common  in  married  than 
in  unmarried  women,  due  to  the  effect  of  parturition.  The  dorsal 
position  with  an  habitually  full  bladder,  relaxation  of  the  ligaments, 
and  getting  out  of  bed  too  early  after  labor  are  also  causes. 

Relaxation  of  the  utero-sacral  ligaments  alone,  caused  by  para- 


Retroversion  and  Retroflexion  of  the  Uterus. 

metritis  posterior  or  combined  with  anterior  fixation  of  the  cervix, 
due  to  shortening  of  the  utero-vesical  ligaments,  will  result  in 
posterior  displacements,  and  is  their  most  common  cause. 

These  conditions  being  present,  the  distended  bladder  pushes  the 
uterus  back,  and  the  intra-abdominal  pressure  comes  to  act  directly 
on  the  anterior  wall,  completing  the  displacement. 

Flexions  result  from  differences  in  the  nutrition  of  the  anterior 
and  posterior  uterine  walls. 

What  are  the  complications? 

There  is  usually  more  or  less  catarrhal  endometritis  present. 
The  uterus  is  enlarged  and  rigid,  due  to  metritis.  The  ovaries 
become  displaced,  enlarged,  and  tender.  Relaxation  of  the  anterior 
vaginal  wall,  with  prolapse,  is  a  common  complication.  Peritonitic 
adhesions,  forming  between  the  fundus  uteri  and  the  rectum,  are 
complications. 


108  DISEASES    OF    THE    UTERUS. 

What  are  the  symptoms  of  retroversions  and  flexions  ? 

Menorrhagia  and  metrorrhagia  ;  sterility  ;  painful  micturition  and 
defecation  ;  tender  ovaries,  due  to  traction  and  displacements  and 
causing  iliac  pain;  backache;  leucorrhoea;  dysmenorrhoea ;  tend- 
ency to  abortion  ;  reflex  neuroses. 

What  is  the  diagnosis? 

This  is  determined  by  digital  and  bimanual  examination.  The 
cervix  will  be  found  pointing  forward  nearer  the  vulva,  and  in  the 
anterior  part  of  the  pelvis.  The  finger  being  passed  backward 
along  the  posterior  wall  of  the  cervix  into  the  posterior  fornix,  the 
fundus  uteri  will  be  felt.  In  retroversions  the  body  is  directly 
continuous  with  the  cervix.  In  retroflexions  a  sulcus  or  kink  will 
be  found  in  the  posterior  wall,  and  it  is  more  difiicult  to  recognize 
the  connection  between  the  body  and  cervix.  This  last  can  best 
be  accomplished  by  bimanual  examination.  The  body  moves  with 
the  cervix,  and  the  sound  passes  backward. 

For  what  might  you  mistake  retroversions  and  flexions? 

Tumors  and  exudation  masses  behind  the  uterus.  Bimanual 
examination  will  always  show  the  presence  of  the  uterine  body  in 
front  of  a  tumor.  The  uterine  sound  may  be  employed,  except 
during  the  acute  stage  of  inflammation.  Drawing  down  the  uterus 
with  the  volsellum  will  often  show  the  relation  of  the  fundus  to 
the  tumor. 

What  is  the  treatment? 

Indications :  (1)  Cure  the  exciting  complications ;  (2)  replace 
the  uterus  ;  (3)  retain  in  position.  Retroversion  due  to  arrest  of 
development  can  usually  be  easily  replaced,  but  it  is  difficult  to 
keep  in  position.     Pregnancy  has  a  favorable  influence  upon  this. 

When  due  to  senile  involution,  as  a  rule,  there  are  no  symptoms, 
and  therefore  no  treatment  is  required.  When  due  to  anterior  fixa- 
tion of  the  cervix,  promote  absorption  of  the  results  of  parametri- 
tis. When  due  to  high  posterior  fixation  of  the  cervix,  treat  the 
posterior  parametritis.  W^hen  due  to  shrinking  of  the  posterior 
wall  or  elongation  of  the  anterior  wall,  remove  tumors  or  inflam- 
matory condition  and  place  an  intra-uterine  stem.  When  due  to 
relaxations  of  the  utero-sacral  ligaments,  the  treatment  consists  in 
replacing  the  uterus  and  keeping  it  in  position  by  a  suitable  pes- 
sary. 


DISPLACEMENTS   OF   THE   UTERUS.  109 

What  methods  are  employed  to  replace  a  retroverted  uterus? 

(1)  Bimanual  vagino-abdominal  and  recto-abdominal  manipula- 
tion ;  (2)  sound  and  uterine  repositor ;  (3)  genu-pectoral  position 
and  manipulation  ;    (4)   Sims's  position. 

Describe  the  bimanual  method. 

This,  as  described  by  Shultze,  is  said  by  him  to  be  the  "  only 
proper  method."  The  patient  being  placed  in  the  dorso-horizontal 
position,  the  index  and  middle  fingers  of  the  left  hand  are  intro- 
duced into  the  posterior  fornix  of  the  vagina,  or,  if  this  does  not 
reach  high  enough,  they  may  be  introduced  into  the  rectum.  The 
body  of  the  uterus  is  now  pushed  upward  on  one  side  of  the  sacral 
promontory  to  the  brim  of  the  pelvis.  The  right  hand,  on  the 
abdomen,  now  grasps  the  fundus  and  draws  it  forward,  while  the 
internal  fingers  are  placed  in  front  of  the  cervix  and  push  it  back- 
ward and  upward,  in  this  way  completing  the  reposition. 

Describe  reposition  by  the  uterine  sound. 

This  may  be  employed  when  the  uterus  is  too  sensitive  to  be 
pushed  upward  by  the  fingers,  but  is  always  more  or  less  unsafe. 
The  sound  is  first  enveloped  in  cotton  and  dipped  in  a  carbolic  solu- 
tion. It  is  then  introduced,  concavity  backward,  and  the  handle 
made  to  describe  a  circle  from  behind  forward;  then  slowly  de- 
pressed, throwing  the  uterus  forward. 

Describe  the  genu-pectoral  position. 

This  method  is  applicable  when  a  gravid  uterus  becomes  wedged 
below  the  sacral  promontory.  The  patient  being  placed  in  the  genu- 
pectoral  position,  the  cervix  is  grasped  with  a  pair  of  volsella  or 
bullet  forceps  and  drawn  down  ;  at  the  same  time  the  fundus  is 
pushed  forward  by  the  finger  in  the  rectum. 

What  is  the  treatment  by  Sims's  position? 

The  patient  is  placed  in  Sims's  position  and  the  fingers  of  the 
right  hand  introduced  into  the  posterior  fornix.  The  fundus  uteri 
is  first  raised  to  the  brim  of  the  pelvis  ;  then  during  expiration 
the  fingers  are  shifted  in  front  of  the  cervix,  and  this  is'  pushed 
strongly  backward,  completing  the  reposition. 

Describe  the  method  of  treatment  in  cases  where  the  fundus  is 
fixed  posteriorly  by  adhesions. 

Gentle  massage  of  the  adhesions  through  the  posterior  fornix 


110 


DISEASES   OF   THE   UTERUS. 


with  one  or  two  fingers  for  five  or  ten  minutes  at  a  time,  stretching 
the  adhesions  at  the  same  time  by  gently  pushing  up  the  fundus  ; 
hot  douches  and  sitz-baths ;  boroglycerite  or  iodide-of-potash  tam- 
pons, pushed  well  into  the  posterior  fornix  and  allowed  to  remain 
twelve  to  twenty-four  hours.  Forcible  breaking  up  of  adhesions 
under  angesthesia  by  bimanual  manipulations  is  sometimes  resorted 
to,  but  is  dangerous. 

How  is  the  uterus  retained  in  position  after  reposition? 
By  pessaries  and  operations. 

PESSARIES. 

What  are  the  best  varieties  ? 

(1)  Figure-of-eight,  made  of  copper  wire  covered  with  soft  rub- 
ber, or,  after  being  fitted,  copied  in  hard  rubber.  (2)  Sledge-shaped, 
made  of  same  materials.  (3)  Hodges'  and  its  various  modifications 
by  Emmet,  Thomas,  and  Albert  Smith. 

What  is  the  main  object  to  be  attained  by  a  pessary  ? 

The  retention  of  the  cervix  backward,  not  the  pushing  of  the 
fundus  forward. 

Describe  the  figure-of-eight  pessary. 

A  ring  of  the  materials  named,  and  of  suitable  size  for  the  case, 

is  first  drawn  out  into  an  oval  shape, 
Fig.  54.  and  then  twisted  on  itself,  forming 

two  loops,  the  upper  one  small  and 
curved  upward,  the  lower  one  larger, 
somewhat  pointed  at  its  extremity, 
and  curved  down. 

Describe  the  sledge  pessary. 

The  same  ring  is  first  drawn  into 
an  oval  form,  and  then  one  end, 
which  is  to  be  the  lower,  is  bent  for- 
ward on  inself  and  flattened.  Hodges' 
pessary  and  its  modifications  are 
made  of  hard  rubber. 

The  Albert  Smith  pessary  is  nar- 
row at  the  lower  end  and  curved  down,  broader  at  the  upper  end 
and  curves  up  behind  the  cervix. 


Hodges'  Closed  Lever  Pessary. 


DISPLACEMENTS   OF   THE   UTERUS. 


Ill 


The 


Fig.  55. 


What  is  the  method  of  introducing  a  pessary  ? 

This  may  be  done  in  the  Sims  or  dorso-horizontal  position, 
pessary  is  grasped  firmly  be- 
tween the  thumb  and  fore- 
finger of  the  right  hand  by  its 
lower  extremity.  The  labia 
are  separated  by  the  left  hand 
from  below.  Introduce  the 
pessary  first  in  a  vertical  or 
slightly  oblique  axis,  pressing 
strongly  down  on  the  peri- 
neum, thereby  gaining  room. 
As  soon  as  the  ostium  vaginae 
is  passed  halfway,  turn  the 
pessary  into  a  horizontal  posi- 
tion and  continue  the  intro- 
duction by  the  index  finger  of 
the  right  or  left  hand  placed 
against  the  internal  loop  or 
bar,  and  carry  this  along  the 
posterior  wall  up  behind  the 
cervix,  as  shown  in  the  figure. 

In  the  figure-of-eight  pessary  the  cervix  must  be  fitted  into  the 
smaller  loop. 

The  sledge  pessary  is  particularly  adaptable  to  relaxed  conditions 
of  the  pelvic  floor. 

What  are  the  contraindications  to  the  use  of  pessaries  ? 

They  should  never  be  used  until  all  pelvic  inflammation  has  been 
removed.  They  should  rarely  be  used  unless  the  uterus  can  be 
thoroughly  replaced. 

How  long  may  a  pessary  remain  in  situ  ?  and  what  precautions 
are  to  be  observed? 

A  pessary  should  be  removed  once  a  month,  cleaned,  and  replaced. 
After  the  introduction  of  a  pessary  for  the  first  time  the  patient 
must  be  questioned  as  to  pain  or  discomfort  in  walking,  sitting 
down,  crossing  the  legs,  etc.  She  should  be  told  to  remove  it  if 
it  causes  pain.  She  should  be  seen  every  day  for  a  few  days,  to 
see  that  the  uterus  remains  in  position. 


Albert  H.  Smith's  Pessary. 


Fig.  56. — Introduction  of  Pessary. 


Fig.  57.— Introduction  of  Pessary. 
112 


DISPLACEMENTS   OF   THE   UTERUS. 


113 


What  operative  procedures   may  be  resorted  to  for  retaining  a 
replaced  retroverted  or  retroflexed  uterus  ? 

(1)  Shortening  the  round  ligaments  (Alexander's  operation),  now 
rarely  resorted  to ;  (2)  ventro-fixation  or  hysterorrhaphy ;  (3j 
Shiicking's  operation. 

Describe  Alexander's  operation. 

The  mons  veneris  is  shaved  and  prepared  antiseptically.  An 
incision  is  made,  IJ  to  3  inches  in  length,  parallel   to  Poupart's 

Fig.  58. 


The  Pessary  in  Position. 

ligament,  in  an  outward  direction  from  the  pubic  spine.  This  in- 
cision is  made  down  to  the  intercolumnar  fascia  covering  the  ring, 
which  is  indicated  by  the  oblique  fibres  crossing  the  ring  and  by 
the  protrusion  of  fat  at  the  lower  end.  The  protruding  tissue,  in- 
cluding the  round  ligament,  is  now  lifted  by  an  aneurism  needle, 
8— Gyn. 


114  DISEASES  OF   THE   UTERUS. 

grasped  by  the  fingers,  pulled  out,  and  sutured  to  the  pillars  of  the 
ring.  The  same  thing  is  done  for  the  other  side.  The  wound  is 
now  closed  with  catgut,  silk,  or  silver  wire,  and  the  usual  anti- 
septic dressings  applied.  The  patient  is  kept  in  bed  for  two  or 
three  weeks,  and  a  pessary  must  be  worn  for  some  months. 

The  operation  is  rapidly  going  into  disuse,  on  account  of  its 
being  unsuccessful  in  permanently  holding  the  uterus  forward,  and 
owing  to  its  establishing  one  pathological  condition,  anteversion 
with  fixation,  for  another.  It  is  also  inapplicable  unless  the  uterus 
is  replaceable,  and  does  not  influence  the  relaxation  of  the  utero- 
sacral  ligaments,  which  is  the  main  cause  of  the  displacement. 

Describe  the  operation  of  ventro-fixation. 

This  is  accomplished  by  laparotomy,  and  is  indicated,  rarely,  when 
all  other  means  have  failed  and  there  is  considerable  posterior 
fixation.  An  incision  is  made  in  the  median  line  of  the  abdomen, 
as  for  any  abdominal  section.  The  adhesions  of  the  uterus  are 
broken  up,  and  the  fundus  brought  forward  and  sutured  to  the 
anterior  abdominal  wall  with  chromicized  catgut  or  silk  sutures. 
The  abdominal  incision  is  closed  in  the  usual  manner.  A  pessary 
must  be  worn  here  also  for  some  time. 

Describe  Shucking's  operation  briefly. 

The  uterus  having  been  replaced  and  held  anteriorly  and  to  one 
side,  a  sound  is  passed  into  the  bladder  and  pushed  strongly  to  the 
other  side  to  avoid  injury  to  the  bladder-wall.  A  curved  canula, 
containing  a  concealed  needle  threaded  with  carrying  thread,  is 
now  introduced  to  the  fundus  of  the  uterus.  The  needle  is  pushed 
forward  by  its  handle  through  the  canula.  piercing  the  uterine  wall, 
curving  downward,  and  appearing  through  the  anterior  vaginal 
wall  near  the  cervix.  The  carrying  thread  is  then  grasped  and 
the  needle  and  canula  withdrawn.  A  loop  of  floss  silk  is  passed 
through  the  loop  of  carrying  thread  and  drawn  back  and  out  at 
the  external  os.  The  two  ends  are  now  tied  together,  producing 
a  pathological  anteflexion. 

DESCENT  AND  PROLAPSE   OF  THE    UTERUS. 
Define  these. 

The  uterus  is  said  to  descend  when  it  comes  to  lie  at  a  lower 
plane  in  the  pelvis  than  normal,  and  a  digital  examination  encoun- 
ters the  vaginal  portion  too  soon.     Prolapse  is  said  to  take  place 


DISPLACEMENTS   OF   THE   UTERUS.  115 

when  the  vaginal  portion  emerges  from  the  vulva  (Shultze).  The 
latter  may  be  incomplete  when  the  cervix  just  appears  at  the  vulva, 
or  complete^  in  which  the  uterus  lies  entirely  outside  the  body 
between  the  thighs.  It  is  always  accompanied  by  more  or  less 
complete  inversion  of  the  vagina  and  prolapse  of  the  posterior 
bladder-wall. 

Other  displacements  may  coexist  with  descent  and  prolapse. 
The  uterus  is  usually  retroverted  and  flexed. 

What  are  the  etiology  and  anatomy? 

The  uterus  is  maintained  in  position  by  the  support  of  the 
vagina,  the  bladder,  its  own  ligaments,  and  the  pelvic  floor. 

The  predispomig  causes  of  prolapse  are  childbirth,  causing  a 
relaxed  condition  of  the  vagina,  and  of  the  peritoneal  and  liga- 
mentary  attachments  of  the  uterus ;  retroversions,  due  to  an 
habitually  distended  bladder.  In  these  cases  the  intra-abdominal 
pressure,  acting  through  the  intestines,  is  brought  to  bear  upon 
the  uterus  unsupported  by  the  bladder,  and  descent  and  prolapse 
result ;  relaxation  of  the  pelvic  floor,  such  as  is  produced  by  lacera- 
tion of  the  perineum  and  in  old  age ;  and  laborious  occupation  and 
increased  weight  of  the  uterus. 

The  exciting  causes  may  be  acute,  blows,  falls,  severe  exertion, 
heavy  lifting,  etc.,  or  chronic,  which  is  much  more  common.  The 
chronic  causes  are  practically  the  same  as  the  above  predisposing 
causes,  resulting  in  gradual  relaxation  of  the  uterine  supports. 

Hypertrophies  of  the  cervix,  either  of  the  infravaginal,  supra- 
vaginal, or  intermediary  portion,  and  usually  accompanied  by  pro- 
lapse, abdominal  tumors,  and  ascites,  are  caused  by  pressure  of  the 
uterus  downward. 

What  are  the  symptoms  and  diagnosis? 

The  symptoms  of  descent  are  those  of  retroversion  and  any  coex- 
isting complications.  The  symptoms  of  the  acute  form  are  violent 
pain,  vomiting,  vertigo,  fainting,  followed  by  retention  of  urine,  and 
signs  of  peritonitis  ;  of  the  chronic  form  are,  first,  a  feeling  of 
weight  and  tension  in  the  hypogastric,  iliac,  and  sacral  regions, 
followed  by  frequent  and  difficult  micturition  ;  in  complete  prolapse 
discomfort  from  the  protrusion  and  excoriation  of  the  parts. 

What  is  the  diagnosis? 

Inspection  when  the  prolapse  is  partial  shows  the  prolapsed  ante- 
rior and  posterior  vaginal  wall,  the  protruding  cervix  and  os  in  the 


116  DISEASES   OF   THE   UTERUS. 

centre.  Ascertain  by  vaginal  examination  whether  the  anterior 
and  posterior  fornices  are  in  their  normal  position  or  are  driven 
down.  If  the  anterior  fornix  is  obliterated  and  the  posterior  for- 
nix normal,  there  will  be  an  hypertrophy  of  the  intermediary  por- 
tion of  the  cervix. 

When  the  prolapse  is  complete,  the  external  covering  of  the 
tumor  can  be  distinguished  as  the  vaginal  wall  by  its  smooth,  dry 
surface  and  remains  of  columnse  rugarum.  The  external  os  is  at 
the  apex  of  the  tumor.  By  palpation  the  body  of  the  uterus  can 
be  felt,  and  it  is  characteristic  in  shape.  A  sound  introduced  into 
the  cavity  is  a  convincing  proof  after  fornices  of  the  vagina  are 
obliterated. 

The  uterus  is  usually  enlarged  and  the  cervix  hypertrophied  and 
eroded  in  complete  prolapse.  A  sound  introduced  into  the  blad- 
der through  the  urethra  reveals  the  extent  to  which  the  bladder  is 
displaced. 

For  what  conditions  may  prolapse  be  mistaken? 

(1)  Hypertrophies  of  the  cervix  without  prolapse ;  (2)  prolapse 
of  the  vagina  ;  cystocele  and  rectocele  ;  (3)  prolapse  of  an  inverted 
uterus ;  (4)  uterine  polypus ;  (5)  tumors  of  the  vagina  or  vulva. 

One  diagnostic  mark  of  prolapse  is  that  the  tumor  is  reducible, 
but  the  diagnosis  should  first  be  made  before  reduction. 

What  is  the  treatment? 

PropJiylactic :  By  preventing  laceration  of  the  perineum,  and  by 
timely  and  appropriate  treatment  of  retroversions. 

Immediate :  (1)  Replace  the  uterus,  and  keep  it  in  position  by 
pessaries  or  operations  ;  (2)  amputation  of  the  cervix  ;  (3)  vaginal 
hysterectomy. 

Reposition  in  difficult  cases  is  best  accomplished  in  the  knee- 
elbow  position.  When  first  replaced  the  uterus  is  usually  in  retro- 
flexion, and  the  reposition  should  be  completed  by  the  hand  on  the 
abdomen.  A  cradle  pessary  or  an  Albert  Smith  in  slight  prolapse, 
without  rupture  of  the  perineal  body,  will  usually  suffice  to  retain 
the  uterus. 

The  various  operative  measures  for  cure  of  prolapse  are — (1) 
repair  of  the  perineum  and  narrowing  of  the  vulva  by  uniting  the 
lower  portion  of  the  labia  majora  (episio-perineorrhaphy) ;  (2)  nar- 
rowing of  the  vagina  (colporrhaphy)  ;  (3)  combination  of  the  above 
methods ;  (4)  peritoneal  fixation  and  Alexander's  operation  ;  (5) 


DISPLACEMENTS   OF   THE   UTERUS. 


117 


amputation  of  the  cervix  alone  or  with  any  of  the  above  ;  (G)  vagi- 
nal hysterectomy  (extirpation  of  the  uterus). 

Repair  of  the  perineum  and  uniting  the  lower  portion  of  the 
labia  majora  are  indicated  in  cases  of  slight  prolapse  with  a  torn 
perineum. 

When  the  prolapse  is  more  extensive  a  combination  of  Hegar's 
posterior  colporrhaphy  and  perineorrhaphy  with  a  Martin's  ante- 

FiG.  59. 


Diagram  representing  some  of  the  Minor  Forms  of  Uterine  Displacement. 

rior  colporrhaphy  will  in  the  majority  of  cases  suffice  to  hold  the 
uterus  in  position.  Amputation  of  the  cervix  is  indicated  in  hyper- 
trophies of  the  latter. 

Vaginal  hysterectomy  is  only  resorted  to  in  those  cases  of  com- 
plete prolapse  where  other  means  of  treatment  seem  useless. 

Describe  briefly  the  minor  displacements  of  the  uterus  mentioned 
under  Varieties. 

Elevation  results  from  myomata,  ovarian  cysts  (especially  those 


118  DISEASES   OF   THE   UTERUS. 

between  the  folds  of  the  broad  ligaments),  haematocolpos,  cicatricial 
contraction  in  the  folds  of  Douglas,  and  superior  fixation,  due  to 
perimetritic  adhesions  after  pregnancy. 

Anteposition,  due  to  retro-uterine  tumors,  chiefly  pelvic  hasmato- 
cele. 

Retroposition  is  due  usually  to  peri-  and  parametritic  inflamma- 
tions. 

Later o-positions.  versions,  and  flexion  are  usually  due  to  inflam- 
matory exudations  and  tumors  to  one  or  other  side  of  the  uterus 
or  to  arrests  of  development. 

ACUTE  METRITIS. 

Define  acute  metritis. 

An  acute  inflammation  of  the  parenchyma  of  the  uterus  (mus- 
cular and  connective  tissue). 

What  are  its  causes? 

Almost  always  septic. 

(a)  Sepsis  after  labor  or  abortion  ;  (li)  sepsis  from  other  causes 
(as  after  the  sudden  evacuation  of  a  large  amount  of  retained  secre- 
tions), from  the  use  of  sponge  tents,  from  any  operation  upon  the 
uterus  without  antiseptic  precautions  ;  (c)  acute  endometritis ;  (d) 
acute  perimetritis  ;  (e)  intra-uterine  injections  or  stem-pessaries  ; 
(  /)  caustics  and  cutting  instruments  used  within  the  uterine  cavity  ; 
(^)  exposure  to  cold  and  wet  at  menses ;  (K)  excessive  coitus, 
especially  at  menses  ;  (i)  gonorrhoeal  infection  ;  (y)  direct  injury  ; 
(]{■)  rarely  from  a  simple  vaginal  pessary. 

What  is  its  pathology? 

It  generally  includes  more  or  less  endometritis  and  perimetritis. 
The  uterus  is  hyperaemic,  infiltrated  with  serum  and  leucocytes,  and 
is  soft  and  succulent.  There  may  be  ecchymoses.  There  may,  in 
addition,  be  small  collections  of  pus  or  abscesses  of  considerable 
size.  There  is  catarrhal  endometritis  with  its  characteristic  dis- 
charge. 

What  are  its  symptoms? 

Sudden,  sharp  chill  ;  fever,  103°  or  104°  F.,  usually  of  a  sthenic 
type,  with  a  full  rapid  pulse;  pain,  heavy  and  dragging;  also  a 
good  deal  of  intermittent,  sharp  pain  (peritonitic)  ;  vesical  and  rec- 
tal tenesmus;  uterus  extremely  sensitive  to  the  touch;  discharge 


CHRONIC   METRITIS.  119 

due  to  the  endometritis ;  nausea  and  vomiting  (especially  if  peri- 
tonitis exists). 

What  is  the  course  of  the  disease  ? 

(1)  Mild  cases  may  recover  completely  in  a  few  days  or  may 
leave  a  chronic  metritis.  (2)  Cases  with  formation  of  abscesses 
have  repeated  chills,  irregular  rise  of  temperature,  sweating.  The 
abscess,  if  small,  may  disappear.  A  large  abscess — 1,  may  become 
encapsulated ;  2,  may  rupture  into  the  peritoneal  cavity — usually 
fatal ;  3,  may  rupture  into  the  uterine  canal,  when  the  prognosis 
is  favorable  ;  or,-4,  may  rupture  into  the  rectum,  bladder,  or  through 
the  abdominal  wall. 

Upon  what  is  the  diagnosis  based? 

(1)  Upon  the  cause  and  symptoms ;  (2)  upon  the  physical  signs. 
These  are  tenderness  on  pressure  or  on  attempting  to  raise  or  depress 
the  uterus  ;  enlargement,  chiefly  antero-posterior,  giving  the  uterus 
a  globular  feel,  such  as  it  presents  in  early  pregnancy. 

What  is  the  prognosis  ? 

The  prognosis  is  grave,  owing  to  the  danger  of  abscess-formation. 

What  is  the  treatment? 

(1)  In  the  early  stages  antiphlogistic :  long-continued  hot 
vaginal  douches  ;  leeches  applied  to  the  groins  ;  ice-bag  over  the 
hypogastrium ;  recumbent  posture  with  the  hips  elevated ;  a 
cathartic  (castor  oil).  If  due  to  sepsis,  the  uterine  cavity  should 
be  repeatedly  irrigated  with  1  :  40  carbolic ;  opium  is  required  to 
relieve  pain. 

(2)  In  the  later  stages,  essentially  a  chronic  metritis,  hot  vaginal 
douches  ;  glycerin  tampons  ;  scarification  of  the  cervix. 

(3)  When  an  abscess  forms,  wait  until  it  points  ;  then  incise  it. 
But  where  it  is  distinctly  extending  toward  the  peritoneal  surface, 
it  is  better  not  to  wait,  but  at  once  to  evacuate  it  through  the 
uterine  canal  or  the  vagina. 

CHRONIC  METRITIS. 
Define  chronic  metritis. 

An  enlargement  of  the  uterus,  due  to  an  increase  in  connective 
tissue,  and  in  which  the  uterus  is  sensitive  to  pressure.  (This  in- 
cludes subinvolution.) 


120  DISEASES   OF   THE    UTERUS. 

What  different  opinions  are  held  in  regard  to  its  occurrence? 

(1)  Some  authors  say  that  it  never  occurs  ;  (2)  some  say  that 
it  is  the  most  frequent  disease  of  women  ;  (3)  Seifert  considers  it 
merely  subinvolution  ;  (4)  Klob,  followed  by  Thomas,  considers  it 
merely  areolar  hyperplasia  following  long-continued  congestion ; 
(5)  Tuttle's  definition  is  as  stated  above. 

What  are  the  predisposing  causes? 

(1)  Any  disease,  acute  or  chronic,  impairing  the  general  health ; 
(2)  frequently-repeated  parturition  or  abortion. 

What  are  the  existing  causes? 

A.  Those  producing  subinvolution  :  (1)  Getting  up  too  early 
after  parturition  ;  (2)  retention  of  placenta,  membranes,  or  clots ; 
(8)  pelvic  peritonitis  or  cellulitis ;  (4)  laceration  of  the  cervix ;  (5) 
all  forms  of  septic  infection ;  (6)  early  resumption  of  hard  work ; 
(7)  early  resumption  of  coitus ;  (8)  non-lactation  ;  (9)  abortion  if 
the  woman  gets  up  and  resumes  sexual  relations  too  early.  As  a 
result  of  these  the  retrograde  metamorphosis  does  not  take  place, 
and  the  uterus  is  left  with  an  abnormal  amount  of  connective  and 
muscular  tissue. 

B.  Causes  producing  constant  or  repeated  active  hypergemia :  (1) 
Excessive  coitus ;  (2)  intercourse  with  impotent  men  ;  (3)  cold 
douches  to  prevent  conception  ;  (4)  masturbation  ;  (5)  obstructive 
dysmenorrhoea ;  (6)  neglected  gonorrhoeal  endometritis. 

C.  Those  producing  passive  congestion :  (1)  Interference  with 
the  general  circulation  by  lesions  of  the  heart,  lungs,  or  liver ;  (2) 
local  obstruction  by  tumors  or  inflammation  (especially  by  habitual 
distension  of  rectum  or  bladder). 

D.  Comparatively  rarely  has  been  preceded  by  acute  metritis. 

Describe  its  pathology. 

There  is  a  proliferation  of  connective  tissue,  chiefly  localized 
about  the  blood-vessels.  There  is  no  noticeable  increase  of  mus- 
cular tissue.  The  lymphatic  spaces  are  dilated.  The  uterus  is 
always  enlarged,  but  not  usually  very  greatly. 

In  the  Jirst  stage  the  new  connective  tissue  is  being  produced. 
The  uterus  is  enlarged,  globular,  antero-posterior  diameter  increased, 
and  is  soft  and  succulent.  It  thus  resembles  the  uterus  in  early 
pregnancy.     The  mucous  membrane  is  congested. 

The  second  stage^  or  the  stage  of  cirrhosis,  is  not  often  observed. 
The  new  connective  tissue  contracts,  forming  irregular  bands  or 


CHRONIC   METRITIS.  121 

cicatrices  or  nodules.  This  tends  to  obliterate  the  blood-vessels, 
and,  as  the  arteries  are  comparatively  thick-walled,  the  venous 
circulation  is  most  impaired.  The  size  of  the  uterus  may  be 
diminished.  It  is  firm  and  white,  cutting  almost  like  cartilage. 
The  uterine  cavity  is  larger  than  normal. 

As  to  site^  chronic  metritis  may  be  general  or  may  be  confined 
chiefly  to  either  the  body  or  the  cervix. 

Describe  chronic  metritis  of  the  cervix  alone. 

This  is  found  in  cases  of  uterine  or  vaginal  prolapse.  In  the 
first  stage  the  os  externum  is  engorged  and  patulous,  the  lips  are 
separated,  and  the  mucous  membrane  everted.  In  the  second  stage 
the  cervix  is  hard,  irregular,  and  nodular  ;  the  lips  are  broad  and 
thick  ;  there  is  chronic  cervical  catarrh.  The  nodular  masses  in  the 
cervix  are  characteristic,  and  closely  resemble  commencing  carcinoma. 

What  are  the  symptoms  of  subinvolution  resulting  in  chronic 
metritis  ? 

The  trouble  dates  from  a  labor  or  abortion  (especially  abortion, 
as  the  patient  gets  up  too  early,  that  her  friends  may  not  suspect 
the  nature  of  the  trouble,  and  is  also  apt  to  resume  intercourse  too 
early). 

a.  In  the  early  stages  there  are — (1)  a  sense. of  weight  and 
pressure  and  dragging  pain,  increased  by  walking  or  standing ; 
(2)  pain  in  the  hypogastrium  or  groin  (apt  to  place  hand  over 
pubes  to  support  the  uterus) :  patients  cannot  ride  over  rough 
pavements,  and  they  walk  carefully ;  (3)  vesical  irritability ; 
(4)  obstinate  constipation ;  (5)  leucorrhoea  and  menorrhagia  or 
metrorrhagia ;  (6)  dyspareunia ;  (7)  many  of  the  signs  of  preg- 
nancy (often  there  is  morning  vomiting,  the  breasts  may  be  en- 
larged and  pigmented,  and  the  patient  may  have  the  subjective 
symptoms  of  pregnancy),  but  there  is  no  cessation  of  menstruation. 

h.  In  the  later  stages  there  are  occasional  acute  exacerbations, 
each  leaving  the  uterus  a  little  larger.     These  are — general  debility  ; 
pains  (sciatic,  sacral,  or  coccygeal),  neuralgias,  headaches,  sterility, 
or  repeated  abortions. 
What  are  the  symptoms  of  chronic  metritis  from  congestion  ? 

There  is,  first,  dysmenorrhoea,  and  in  the  course  of  years  the 
general  health  is  impaired  and  the  uterus  becomes  enlarged,  pain- 
ful, and  sensitive.  There  are  leucorrhoea  and  menorrhagia  or 
metrorrhagia.  The  patient  finally  presents  the  same  symptoms  as 
one  in  whom  the  chronic  metritis  originated  in  subinvolution. 


122  DISEASES   OF   THE   UTERUS. 

What  are  the  physical  signs  of  chronic  metritis  ? 

a.  Early  stage  :  Uterus  uniformly  enlarged  and  sensitive  ;  uterus 
usually  prolapsed,  and  there  is  often  retroflexion  and  fixation.  The 
uterine  cavity  is  always  enlarged  and  more  roomy.  The  uterine 
walls  are  doughy.  The  cervix  in  a  nullipara  is  enlarged,  swollen, 
and  tapers  to  a  point,  where  the  os  is  patulous,  eroded,  and  presents 
a  plug  of  mucus.  The  cervix  in  a  multipara  is  blunt  and  swollen, 
the  OS  is  broad  and  its  lips  are  swollen  and  eroded.  There  is  cer- 
vical catarrh. 

h.  Later  stages :  The  cervix  is  indurated  and  nodular,  and  is 
larger  than  the  body  of  the  uterus.  The  body  of  the  uterus  is  not 
sensitive  to  pressure. 

What  are  the  complications  of  chronic  metritis  ? 

Chiefly   inflammatory.      (1)    Peritoneal    adhesions    and    bands ; 

(2)  acute  and  chronic  ovaritis  ;  (3)  distortions  of  the  tubes  (some- 
times hydrosalpinx)  ;  (4)  displacements  of  the  uterus  ;  (5)  endo- 
metritis ;  (6)  disturbances  of  menstruation. 

What  are  the  chief  diagnostic  features  of  chronic  metritis  ? 

(1^    Uniform    enlargement    of    the    uterus ;    (2)    sensitiveness ; 

(3)  pain  ;    (-4)  chronicity. 

From  what  conditions  must  you  diagnose  chronic  metritis  ? 

(1)  Pregnancy  ;  (2)  fibroid  tumors  of  the  uterus  ;  (3)  carcinoma 
of  the  cervix. 

Give  the  differential  diagnosis  between  pregnancy  and  chronic 
metritis. 
The  symptoms  common  to  both  are  morning  vomiting,  pigment- 
ation and  enlargement  of  the  breasts,  and  changes  in  the  cervix. 
But  in  pregnancy  menstruation  is  absent,  and  in  chronic  metritis 
it  is  irregular  and  profuse. 

What  is  Hegar's  sign  of  pregnancy  ? 

It  is  a  change  in  the  convexity  of  the  posterior  wall  of  the 
uterus  (a  slight  bulging)  above  the  vagina.  It  is  excellent,  but 
the  exclusion  of  chronic  metritis  is  essential. 

Give   the    differential   diagnosis    between  chronic   metritis   and 

fibroids. 

a.  In  the  case  of  a  small  submucous  fibroid  the  uterus  would 

not  be  sensitive,  and  the  uterine  cavity  would  be  smaller.      (In  case 

of  doubt  dilate  the  os  and  examine  the  uterine  cavity  with  the  finger.) 


CHRONIC   METRITIS.  123 

h.  With  an  interstitial  fibroid  the  uterus  is  not  sensitive,  and, 
while  the  cavity  of  the  uterus  is  enlarged,  there  are  none  of  the 
other  symptoms  of  chronic  metritis.  On  bimanual  examination  a 
localized  swelling  of  the  uterine  wall  can  be  felt. 

How  would  you  diagnose  carcinoma  of  the  cervix  from  chronic 
metritis  ? 

By  the  coexistent  cancerous  cachexia ;  by  the  age  (carcinoma 
rarely  occurring  before  thirty-five)  ;  by  microscopical  examination 
of  a  portion  cut  from  the  cervix. 

What  is  the  course  of  the  disease  ? 

Exceptionally  it  may  give  no  serious  trouble,  but  generally  it 
undermines  the  health.  Many  get  worse  at  the  menopause,  and 
then  get  practically  well,  but  some  go  on  for  ten  years  longer,  with 
profuse  and  irregular  menstruation.  The  few  cases  that  pass  into 
the  stage  of  cirrhosis  are  freed  from  almost  all  the  troublesome 
symptoms. 

What  is  the  prognosis? 

When  confined  to  the  cervix  it  may  be  cured.  When  the  whole 
uterus  is  involved  there  is  little  danger  to  life,  but  the  prospect  of 
cure  is  very  poor.  Some  few  cases  are  spontaneously  cured  by 
passing  into  the  second  stage.  The  only  danger  is  from  hemor- 
rhage or  peritonitis. 

What  is  the  prophylaxis? 

Remaining  in  bed  until  the  fundus  is  at  the  level  of  the  sym- 
physis ;  remaining  in  bed  seven  or  eight  days  after  abortion :  lac- 
tation if  possible. 

What  is  the  curative  treatment? 

(1)  Remedying  existing  causes  of  congestion  Ccatarrh  of  the 
cervix,  laceration,  and  displacements). 

(2)  General  Treatment. — Bowels  and  bladder  regulated ;  diet 
wholesome  and  nutritious  ;  iron  if  anaemic  (strychnine,  iron,  and 
quinine  form  an  excellent  tonic)  ;  ergotine  in  doses  of  \  grain  three 
times  a  day  is  almost  a  specific ;  baths,  but  never  cold  nor  sea- 
baths  ;   change  of  climate  is  often  beneficial. 

Weir  Mitchell's  treatment  consists  in  absolute  rest,  a  stuffing 
diet,  electricity,  and  passive  motion.  The  patient  lies  perfectly 
still ;  does  not  make  a  voluntary  motion,  so  much  as  even  to  raise 
a  hand,  for  two  months  ;  receives  a  very  liberal  diet,  and  the  nutri- 


124  DISEASES   OF   THE   UTERUS. 

tion  is  maintained  by  electricity  and  passive  motion  daily.  This  is 
rarely  practicable,  and  where  it  is  not  the  best  treatment  consists 
in  moderate  exercise  in  the  open  air  (a  walk  of  a  mile  or  two  daily, 
no  driving  or  riding),  having  the  patient  keep  at  her  ordinary  work, 
but  avoiding  straining  or  heavy  lifting.  Restrict  sexual  intercourse, 
but  it  is  often  not  best  to  prohibit  it.  (Do  so,  of  course,  if  it  causes 
prostration  or  aggravates  the  symptoms.)  Support  the  uterus  by  a 
suitable  pessary.  Remove  pressure  from  above  by  the  use  of  sus- 
penders, loose  waistbands,  and  a  well-fitting  abdominal  belt.  Reg- 
ulate the  bowels  (this  is  very  important)  :  the  diet  should  not  be 
of  too  great  bulk  and  should  be  laxative  ;  fresh  fruits  are  especially 
desirable.  An  enema  of  1  or  2  drachms  of  glycerin  (undiluted) 
every  night  or  morning  causes  a  satisfactory  movement  of  the  bow- 
els, and  is  free  from  any  objectionable  effects. 

(3)  Local  Treatment. — a.  Local  Depletion. — Scarification,  punc- 
ture, leeches.  Scarification  or  puncture  may  be  done  twice  weekly  ; 
neither  is  contraindicated  by  any  degree  of  anaemia,  and  each  is 
very  effective ;  especially  useful  a  few  days  before  menstruation. 
For  scarification :  longitudinal  incisions  in  the  cervical  mucous 
membrane:  a  straight  bistoury  is  used;  and  for  puncturing:  an 
instrument  called  Buttle's  spear  is  thrust  into  the  cervix  to  the 

Fig.  60. 


Buttle's  Spear. 

depth  of  one-fourth  of  an  inch  in  a  number  of  places.  The 
amount  of  blood  drawn  should  be  ^ss  to  ^ij.  Hemorrhage  is 
readily  checked  by  the  application  of  alum  or  tannin.  It  is  not 
necessary  to  apply  suction,  as  by  cups.  (Do  not  tell  the  patient 
what  you  are  doing,  but  tell  her  that  the  tampons  will  be  stained.) 
Leeches  are  applied  through  a  cylindrical  speculum.  The  cervix 
is  first  plugged  with  a  bit  of  cotton,  and  then  punctured.  Leeches 
are  uncertain  as  to  the  amount  of  blood  they  will  withdraw,  and 
there  is  a  liability  to  profuse  subsequent  hemorrhage. 

h.  Vaginal  Douche.^. — Prolonged  injections  of  hot  water,  100°  to 
110°  F.,  or  of  hot  salt  solution,  are  very  beneficial  in  all  conditions 
where  there  is  congestion. 

How  should  a  vaginal  douche  be  administered? 

"  The  injection  can  be  better  given  after  the  patient  is  undressed 


CHRONIC   METRITIS.  125 

for  the  night  and  in  bed.  She  shoukl  be  placed  near  the  edge  of 
the  bed,  with  the  hips  elevated  as  much  as  possible  by  the  bed-pan, 
and  a  small  pillow  under  her  back,  the  lower  limbs  being  flexed. 
Her  body  must  be  covered  to  protect  her  from  the  cold,  and  her 
position  made  perfectly  comfortable :  whenever  the  bed  is  a  soft 
one,  for  the  purpose  of  keeping  the  hips  elevated  a  broad  board 
should  be  placed  under  the  pan  to  prevent  it  from  sinking  into  the 
bed  from  the  weight  of  the  patient.  The  vessel  of  hot  water  is 
placed  on  a  chair  by  the  bedside,  and  the  nurse  passes  the  nozzle  of 
the  syringe  into  the  vagina,  over  the  perineum,  directing  it  along 
the  recto-vaginal  wall  until  it  has  reached  the  posterior  cul-de-sac. 
The  water  must  be  thrown  in  at  first  very  carefully,  until  the 
vagina  has  become  distended "'  (Emmet). 

A  fountain  syringe  may  be  used  instead  of  the  bulb  syringe,  as 
above  described,  and  in  every  case  the  perforations  in  the  nozzle 
used  should  be  lateral,  to  avoid  the  danger  of  the  fluid  being  in- 
jected into  the  uterine  cavity. 

c.  Tampons. — The  most  useful  are  glycerin  tampons,  with  chlo- 
ral or  iodoform  as  an  anodyne.  Tampons  impregnated  with  alum 
are  not  so  desirable,  as  their  astringent  action  cannot  be  limited  to 
the  cervix,  but  extends  to  the  vagina. 

d.  Counter-irritatw7i. — This  is  best  effected  by  tincture  of  iodine 
or  Churchill's  tincture,  diluted  one-half  with  glycerin  and  applied 
to  the  entire  mucous  membrane  of  the  uterine  canal.  The  canal 
is  first  moderately  diluted  by  graduated  sounds  ;  then  an  applica- 
tor wound  with  cotton  soaked  in  the  solution  is  passed  rapidly 
into  the  uterine  canal  and  allowed  to  dry  there  (always  protect  the 
vagina  from  the  excess).  Then  freely  paint  the  vaginal  surface  of 
the  cervix  with  tincture  of  iodine.  (A  glycerin  tampon  should 
then  be  introduced,  to  be  removed  by  the  patient  in  twenty-four 
hours.)  The  solid  stick  of  nitrate  of  silver  may  be  passed  into 
the  uterine  cavity,  or  the  cervix  may  be  blistered  by  painting  its 
vaginal  surface  with  cantharidal  collodion.  But  these  measures 
are  not  often  necessary. 

e.  Operations. — (1)  Martin's  operation  consists  in  amputation 
of  the  anterior  lip  of  the  cervix.  It  will  often  cause  reduction  in 
the  size  of  the  entire  uterus.  The  objection  to  it  is  the  distortion 
produced.  (2)  Emmet's  operation,  or  trachelorrhaphy,  is  for  the 
repair  of  laceration  of  the  cervix,  and  is  often  followed  by  brilliant 
improvement.  It  is  the  one  to  be  chosen  in  most  cases.  (3)  Schroe- 
der's  amputation  of  the  cervix  consists  in  the  removal  of  a  circular 


126 


DISEASES  OF   THE   UTERUS. 


wedge  and  suturing  the  vaginal  to  the  cervical  mucous  membrane. 
It  is  eflfective  and  is  to  be  preferred  in  some  cases. 


(A) 
1. 
2. 

3. 
4. 
5. 

6. 


9. 
10. 
11. 
12. 


APPLICATIONS   THROUGH  THE  SPECULUM. 

In  substance  (stick,  crystals,  or  powder)  : 
Nitrate  of  silver, 


Caustic  potash. 
Chloride  of  zinc. 
Chromic  acid, 
Alum, 
Tannin, 

Persulphate  of  iron, 
Sulphate  of  copper, 
Iodide  of  lead, 
Iodoform, 

Hydrate  of  chloral. 
The  bromides. 


are  escharotics,  and  must  not  be  kept 
in  contact  with  the  cervix  or 
vagina. 


may  be  kept  in  contact  with  the  cer- 
vix for  several  hours. 


Caustics. 


(B)  Fluids: 

'  Nitric  acid,  fuming. 

Chromic  acid,  sat.  sol.  in  water  or  diluted. 
Escharotics.  ■{  Bromine  sol.  in  alcohol,  1  :  5  or  10. 

Acid  nitrate  of  mercury  (sat.  sol.). 
(^Chloride  of  zinc  (sat.  sol.). 

Nitrate  of  silver  in  strong  solution,  Ij— ^. 

Carbolic  acid,  pure. 
■^  Iodized  phenol,  carbolic  acid,  tr. iodine,  equal  parts. 

Acetic  acid,  pure. 

Pyroligneous  acid  (crude  or  rectified). 
'  Sol.  of  perchloride  of  iron. 

Sol.  of  persulphate  of  iron  (Monsel's). 

Sat.  sol.  of  alum. 

Sat.  sol.  of  acetate  of  lead. 

Sat.  sol.  of  sulphate  of  zinc. 

Sat.  sol.  sulphate  of  copper. 

Glycerites  of  alum  and  tannin. 

Fluid  extract  of  pinus  Canadensis. 

Fluid  extract  of  hydrastis  Canadensis. 

Fluid  extract  of  eucalyptus  globulus. 

Fluid  extract  of  witch  hazel. 
^  Bismuth  and  glycerin. 


Astringents 
and 

Styptics. 


ENDOMETRITIS. 


127 


Alteratives.       < 


r  Tincture  of  iodine. 
Compound  tr.  of  iodine. 
Churchill's  tincture  of  iodine. 
Sol.  of  iodide  of  potash. 
Sol.  of  iodoform  in  glycerin. 
Impure  carbolic  acid  and  glycerin,  equal  parts. 
Sol.  of  nitrate  of  silver,  gr.  x— ^ss  to  ^j. 
Sol.  of  chromic  acid,  .^j  to  ,^j  of  water. 
Sol.  of  sulphate  of  zinc,  10  per  cent. 
Sol.  of  sulphate  of  copper,  10  per  cent. 
Sol.  of  persulphate  of  iron,  with  glycerin,  equal 

parts. 
Sol.  of  perchloride  of  iron,  with   glycerin,   equal 

parts. 


Narcotics. 


Tincture  of  belladonna. 

Tincture  of  hyoscyamus. 

Tincture  of  opium. 

Tincture  of  conium. 

Sol.  of  chloral  hydrate. 

Sat.  sol.  of  bromide  of  potassium. 

Sat.  sol.  of  bromide  of  sodium. 

Sat.  sol.  of  bromide  of  ammonium. 

Cocaine. 


Hydragogue.        Glycerin. 


Disinfectants.    < 


'  Corrosive  sublimate,  1  :  2000. 
Carbolic  acid,  1  :  50. 
Boracic  acid,  sat.  sol. 
Chlorine-water. 
Chlorinated  soda. 
Bromo-chloralum. 
Thymol. 
Permanganate  of  potash. 


ENDOMETRITIS. 
What  are  the  varieties  ? 

(1)  Acute  ;  (2)  chronic. 


128  DISEASES   OF   THE   UTERUS. 

ACUTE   ENDOMETRITIS. 
What  are  its  definition  and  occurrence? 

It  is  an  acute  inflammation  of  tlie  mucous  membrane  of  the  ute- 
rus, and  is  usually  general — i.  e.  not  confined  to  the  cervix  or  to 
the  body  exclusively.  It  is  not  very  common,  and  is  said  never 
to  occur  before  puberty. 

What  are  its  causes? 

(1)  Gonorrhoeal  infection  (there  is  not  necessarily  any  ante- 
cedent infection  of  the  vagina  or  urethra,  but  this  is  quite  often 
the  case).  (2)  Injurious  influences  during  menstruation  (cold, 
local  injuries,  as  by  stem-pessaries,  sounds,  and  intra-uterine  appli- 
cations). (3)  It  may  complicate  typhus  fever,  small-pox,  measles, 
etc.     (4)  Sepsis  after  labor  or  abortion. 

What  is  its  pathology  ? 

The  mucous  membrane  is  red  and  thickened ;  it  is  soft  and  vel- 
vety, and  can  be  stripped  oif  with  a  scalpel.  It  presents  small 
ecchymoses.  The  body  is  more  affected  than  the  cervix.  The 
latter  is  soft,  dark  red  or  purplish,  and  presents  a  ring  of  small 
superficial  erosions  about  the  os.  Secretion  is  increased.  That 
from  the  body  is  at  first  serous,  but  later  becomes  cloudy  from 
desquamated  epithelium,  which  under  the  microscope  is  seen  to 
form  casts  of  the  tubular  glands.  The  secretion  from  the  cervical 
canal  is  yellowish-green  or  rusty,  according  to  the  preponderance 
of  pus  or  blood.     It  excoriates  the  vagina  and  vulva. 

What  are  the  complications  ? 

Acute  salpingitis,  acute  metritis,  acute  peritonitis,  vaginitis. 

What  are  the  symptoms? 

(1)  Chill  not  present  in  the  majority  of  cases.  (2)  Rise  of  tem- 
perature to  100°  or  101°  F.  (3)  No  pain  unless  there  are  compli- 
cations. (4)  After  two  or  three  days  increased  secretion  of  the 
character  above  described.  (5)  In  gonorrhoeal  or  severe  septic 
cases  we  have  added  nausea,  vomiting,  pain,  vesical  tenesmus,  and 
tympanites. 

What  are  the  physical  signs? 

(1)  Bimanual  examination  shows  the  uterus  to  be  of  normal  size 
and  slightly  sensitive.  (2)  The  sound  should  never  be  used  in  an 
acute  process  like  this,  especially  if  gonorrhoeal  or  septic.  It  would 
show  great  sensitiveness  at  the  os  internum  and  at  the  fundus,  and 


CHRONIC   ENDOMETRITIS.  129 

its  use  would  be  followed  by  marked  hemorrhage.  (8)  The  use 
of  the  speculum  would  show  the  os  patulous,  with  a  ropy  secretion, 
and  the  cervix  either  simply  reddened  or  dark  purple,  or  with  exten- 
sive superficial  erosions. 

What  is  the  prognosis  ? 

Doubtful  if  septic  or  gonorrhoea!,  because  of  the  liability  to  com- 
plications. In  other  cases  the  prognosis  is  good  if  the  patient  will 
take  proper  care  of  herself. 

What  is  the  course? 

The  fever  subsides  in  a  few  days,  but  the  discharge  continues 
two  or  three  weeks.  If  neglected  it  may  pass  into  chronic  endo- 
metritis. 

What  is  the  treatment? 

(1)  Rest  in  bed  should  be  insisted  upon  while  the  acute  symp- 
toms last.  (2)  Cathartics,  if  required  to  keep  the  bowels  free. 
(3)  Pain  if  present  is  treated  by  hot  hypogastric  fomentations,  and 
Thomas  uses  opium.  (4)  Vesical  irritation  is  treated  by  mineral 
waters  and  the  salts  of  potash.  (5)  When  the  discharge  becomes 
purulent  simple  vaginal  douches  are  given  (plain  water  or  with 
some  astringent).  (6)  Depletion,  as  by  leeches  or  cups,  is  never 
indicated. 

CHRONIC   ENDOMETRITIS. 
How  frequent  is  its  occurrence? 

It  is  perhaps  the  most  common  of  gynecological  diseases.  It 
may  be  limited  to  either  the  body  or  the  cervix  of  the  uterus,  or 
it  may  be  general. 

CHRONIC  CORPOREAL  ENDOMETRITIS. 

What  are  its  causes? 

(1)  Those  producing  active  hyperaemia.  (2)  Those  producing 
passive  congestion.  (3)  It  may  be  consequent  upon  acute  endo- 
metritis. 

The  causes  most  frequently  operating  are — 1,  sexual  excesses  ; 
2,  local  irritation  by  too  hot  or  too  cold  vaginal  injections  or  by 
injudicious  treatment  by  gynecologists ;  3,  displacements  of  the 
uterus,  especially  prolapse,  and  in  virgins  flexions  and  stenosis  ; 
4,  neoplasm,  especially  fibroids  ;  5.  gonorrhoea  is  the  most  import- 
ant of  all,  and  there  need  not  necessarily  be  a  history  of  vaginitis. 
9— Gyn. 


130  DISEASES   OF   THE   UTERUS. 

What  is  the  pathology? 

The  mucous  membrane  is  congested  and  thickened  (may  be 
^S-  inch,  or  even  i  or  2  inch,  in  thickness) ;  there  are  superficial 
ecchymoses,  which  when  old  appear  as  yellow  or  brown  or  black 
spots ;  the  surface  is  smooth,  velvety,  and  of  a  pinkish  hue,  but 
may  be  thrown  into  folds  or  papillary  masses  completely  tilling 
the  uterine  cavity.  The  utricular  glands  are  dilated,  their  mouths 
being  blocked,  and  some  may  rupture. 

What  varieties  are  distinguishable  microscopically? 

I.  Glandular  endometritis  :  1 ,  hypertrophic  ;  2,  hyperplastic. 
II.  Interstitial  endometritis. 

III.  Mixed  endometritis. 

IV.  Fungous  endometritis. 

Describe  glandular  endometritis. 

(1)  In  simple  or  hypertrophic  glandular  endometritis  there  is 
marked  proliferation  of  the  epithelium  lining  the  utricular  glands. 
Thus  the  glands  become  distorted  and  their  walls  are  thrown  into 
dentate  elevations.  As  seen  from  the  surface,  the  mouths  of  the 
glands  are  irregularly  stellate. 

(2)  In  hyperplastic  glandular  endometritis  new  glands  are  added, 
and  may  be  so  numerous  as  to  fairly  honeycomb  the  mucous  mem- 
brane. They  may  be  diverticula  from  the  general  surface  or  from 
the  old  glands. 

Describe  interstitial  endometritis. 

It  is  chiefly  cellular  in  the  early  stages.  The  round  cells  of  the 
stroma  are  increased  in  size  and  number,  and  have  large  nuclei. 
Later  the  cells  become  spindle-shaped,  the  nuclei  oval  and  less  well 
defined,  and  finally  dense  connective  tissue  results,  which  compresses 
and  distorts  the  glands.  If  the  intercellular  substance  is  princi- 
pally affected,  there  is  marked  production  of  dense  new  connec- 
tive tissue ;  the  glands  are  after  a  time  obliterated  and  the  secre- 
tion destroyed. 

Describe  mixed  or  diffuse  endometritis. 

All  the  elements  of  the  mucous  membrane  are  involved,  but  to 
different  degrees  at  different  parts  of  the  surface.  This  is  the  most 
common  form. 


CHRONIC   ENDOMETRITIS.  131 

Describe  fungous  endometritis,  or  fungoid  degeneration  of  the 
endometrium. 

This  is  a  clinical  class  in  which  a  certain  number  of  growths  (ute- 
rine fungosities)  occur  as  a  result  of  an  endometritis  (most  often  mixed, 
but  it  may  be  glandular  or  interstitial).  To  the  naked  eye  these 
look  like  white  or  red  currants  ;  they  are  very  vascular  and  bleed 
readily.  They  may  be  sessile  or  pedunculated.  Microscopically, 
they  consist  merely  of  hyperplastic  mucous  membrane.  They  are 
said  to  occur  almost  exclusively  after  labor,  or  especially  after 
abortion,  as  the  result  of  chronic  endometritis  set  up  by  retained 
bits  of  placenta. 

What  are  the  symptoms? 

(1)  Hemorrhage  is  the  characteristic  symptom.  (If  the  dis- 
charge is  purulent,  it  probably  comes  from  the  Fallopian  tubes ;  if 
there  is  a  free  watery  discharge,  the  existence  of  a  tumor  is  to  be 
thought  of.)  There  is  profuse  menstruation  and  irregular  hemor- 
rhage between  the  periods. 

(2)  Pain  is  excessive  at  the  periods,  especially  in  the  interstitial 
form.  (In  the  glandular  form  hemorrhage  is  the  most  prominent 
symptom.)  (a)  Dysmenorrhoea,  severe  colicky  pains,  and  there 
may  be  membranous  dysmenorrhoea,  especially  in  virgins.  (6) 
"  Middle  pain  "  is  a  sudden  uterine  colic  occurring  halfway  be- 
tween the  periods.  (c)  Constant  pain  with  exacerbations.  (cT) 
Others  feel  best  at  or  after  menstruation  (especially  those  with 
free  flowing),     (e)  Indefinite  pain. 

(3)  Sensibility  to  the  Sound. — There  are  great  pain  and  hemor- 
rhage on  passing  the  sound.  The  greatest  sensitiveness  is  at  the 
OS  internum  and  at  the  fundus. 

(4)  Sterility  or  a  tendency  to  abortion. 

(5)  Symptoms  like  those  of  pregnancy — "  morning  sickness," 
changes  in  the  breasts. 

(6)  Distiirhance  of  Digestion. — True  dyspepsia  or  a  nervous 
form  characterized  by  a  capricious  appetite  and  distress  after  eating. 

(7)  Disturbance  of  the  Nervous  System. — Melancholia  or  some 
change  of  temperament. 

What  is  the  diagnosis? 

(1)  History.  (2)  Uterine  sound  :  (a)  Grlandular.  The  cavity 
is  lengthened  and  more  roomy.  Sensitiveness  is  not  extreme. 
Rough  excrescences  can  be  felt  at  various  points,     (b)  Interstitial. 


132  DISEASES   OF   THE    UTERUS. 

The  cavity  is  narrow,  and  the  sound  cannot  be  turned  from  side 
to  side.  The  mucous  membrane  is  pretty  smooth,  but  not  elastic, 
and  there  may  be  fungosities.  (c)  Fungous.  The  roughnesses 
are  felt  at  once.  They  may  be  scraped  out  and  the  fungosities 
examined. 

What  are  the  complications? 

In  nulliparae  it  is  not  apt  to  be  complicated  except  in  gonor- 
rhoea! cases,  where  the  inflammation  may  extend  to  the  tubes  and 
peritoneum.  In  multiparae  it  often  causes  metritis,  cervical  catarrh, 
vaginitis,  displacements  of  the  uterus,  or  pruritus  vulvae. 

What  is  the  prognosis? 

Best  in  recent  cases  :  glandular ;  uterus,  not  much  enlarged ; 
cavity  roomy ;  not  much  connective-tissue  formation  ;  not  much 
debility. 

Bad  in  old  cases  :  glands  mostly  deformed  or  obliterated  ;  men- 
struation scanty  ;  pain  excessive  ;  general  health  undermined.  (In 
fifty  per  cent,  of  all  cases  the  climacteric  brings  no  relief  at  all.) 

What  is  the  treatment? 

General. — Tonics  and  hygiene  (especially  regulation  of  bowels, 
bladder,  sexual  relations)  ;  treat  displacements  if  present ;  use  of 
ergotine  if  the  uterus  is  enlarged. 

Local. — (1)  Ointments  may  be  introduced  by  a  long  syringe  and 
left  to  melt  in  the  uterine  cavity.  They  are  unscientific,  uncertain, 
and  useless.  Those  which  have  been  tried  contained  lead,  bismuth, 
iodoform  or  calomel  combined  with  cocoa  butter. 

(2)  Solid  alteratives;  pencils  or  suppositories  containing  iron, 
alum,  tannin,  or  copper.  (The  best  method  is  by  fusing  the  sub- 
stance on  the  end  of  a  copper  wire.  It  takes  four  or  five  minutes 
to  melt  inside  the  uterus.)     These  are  not  very  valuable. 

(3)  Solutions  are  excellent.  The  cervix  is  thoroughly  dilated 
(e.  ^.  by  a  cervical  speculum),  and  an  applicator,  wound  with  cot- 
ton saturated  with  the  solution,  is  passed  quickly  into  the  uterine 
cavity.  The  uterus  contracts,  and  it  is  necessary  to  wait  a  few  sec- 
onds for  it  to  relax  before  withdrawing  the  applicator.  The  most 
desirable  applications  are — a.  Tincture  of  iodine,  pure  ;  h.  Church- 
ill's tincture  of  iodine,  pure  or  with  50  per  cent,  glycerin  ;  c.  Bat- 
tey's  solution  (iodine,  alcohol,  and  carbolic  acid)  ;  J.  Liq.  ferri 
persulph.,  or  liq.  ferri  sesquichloridi  (each  with  50  per  cent,  gly- 
cerin) ;  e.  Saturated  solution  of  zinc  or  copper  sulphate.     Others  are 


CHRONIC   ENDOMETRITIS. 


133 


nitrate  of  silver  or  chromic  acid,  gr.  xx-gj.  and  crude  carbolic  acid. 
Be  sure  there  is  room  for  the  fluid  to  escape,  else  it  may  be  forced 
into  the  tubes. 

(4)  The  dull  curette  (Thomas's  wire  curette.  Fig.  61)  is  used 
for  the  removal  of  fungosities.  The  cervix  is  moderately  dilated, 
and  then  every  portion  of  the  surface  of  the  endometrium  is  cjone 


Fig.  61. 


^^ 


Thomas's  Wire  Curette. 

over  with  the  wire  loop.  Then  a  single  application  is  made  of  a 
solution  of  either  chromic  acid,  nitrate  of  silver,  sulphate  of  zinc 
sulphate  of  copper,  persulphate  of  iron,  chloride  of  zinc,  tincture 
of  chloride  of  iron,  or  carbolic  acid.  The  operation  can  be  done 
without  an  angesthetic. 

(5)  Intra-uterine  Injectio7is. — The   syringe    is  long,  with   lateral 
orifices.     The  fluids  injected  are — tincture  iodine  ;  tincture  iodine, 


Fig.  62. 


Applicator  Syringe  for  Fluids  or  Ointments. 

Churchill's  ;  nitrate  of  silver,  ^ss  or  less  to  gj  ;  pyroligneous  acid ; 
solutions  of  iron,  copper,  or  zinc  salts. 

Contraindications. — (1)  Never  employ  this  method  without  hav- 
ing the  cervix  fully  dilated,  and  never  in  cases  of  acute  flexion. 
(2)  Never  just  before,  during,  or  just  after  menstruation.  (3) 
Never  if  there  is  acute  inflammation  in  or  about  the  uterus. 

Dangers. — (1)  Uterine  colic  and  slight  collapse.  (2)  Fluid  may 
pass  out  through  the  tubes  into  the  peritoneal  cavity.  (3)  Or  into 
the  veins  and  produce  acute  phlebitis.  (4)  Entrance  of  air  into 
the  veins. 

Rules.— (V)  Fluid  should  be  at  least  80°  or  90°  F. ;  (2)  exclude 
air;  (3)  bladder  and  rectum  empty  :  (4)  confine  patient  to  bed  for 
a  few  hours  afterward. 

Methods. — (1)  Bandl's  canula,  pyroligneous  acid.    A  double  tubu- 


134 


DISEASES    OF   THE    UTERUS. 


lar  speculum  is  introduced  (a  long  speculum  with  a  short  wide  one)  ; 
the  cervix  is  seized  by  a  tenaculum  and  drawn  well  down,  the 
long  inner  speculum  being  removed.  Bandl's  canula  is  intro- 
duced about  one-fourth  of  its  length  into  the  uterine  cavity ;  the 


Fig.  63. 


Bandl's  Canula. 


cylindrical  speculum  is  filled  with  crude  pyroligneous  acid,  and  the 
canula  is  pushed  on  into  the  uterus. 

(2)  Tincture  of  iodine,  ten  or  twelve  drops  introduced  into  the 
uterine  cavity  through  a  long  uterine  syringe  with  pinhole  lateral 
orifices. 

(3)  In  old,  long-standing  cases  dilate  the  cervical  canal  thor- 
oughly, and  irrigate  the  uterine  cavity  with  3  per  cent,  carbolic 
acid  by  means  of  the  Fritsch-Bozeman  intra-uterine  catheter.  Then 
scrape  out  the  entire  endometrium  with  a  sharp  curette. 

The  patient  .should  remain  in  bed  for  four  or  five  days,  and 
then  ten  or  twelve  drops  of  pure  tincture  of  iodine  are  injected, 
and  the  patient  may  get  up  twenty -four  hours  later.  The  injection 
of  tincture  of  iodine  should  be  repeated  twelve  times,  at  intervals 
of  two  or  three  days. 

Some  objections  urged  against  this  last  method  are — 
(1)  That  it  is  dangerous.     (It  is  not  dangerous  if   performed 
with  antiseptic  precautions.)     (2)  That  it  is  impossible   to  scrape 
out  the  endometrium.     (Others  say  that  they  can  do  it.)     (3)  That 


CHRONIC   CERVICAL    ENDOMETRITIS.  135 

it  causes  sterility.     (This  is  not  true :  furthermore,  it  sometimes 
cures  sterility.) 

Menstruation  is  generally  absent  the  first  two  periods  after  this 
treatment,  but  returns  at  the  third  period. 

CHRONIC  CATARRH  OF  THE  CERVIX  [CHRONIC  CERVICAL 

ENDOMETRITIS). 

What  is  the  occurrence? 

It  is  the  most  common  gynecological  disease.  In  virgins  and 
nulliparae  it  is  limited  to  the  mucous  membrane ;  in  multiparae  the 
inflammation  involves  all  parts  of  the  cervix. 

What  are  the  causes  ? 

I.  Predhposing. — (1)  Long  conical  cervix  (in  nulliparae)  ;  (2) 
general  debility  from  rheumatism,  gout,  tuberculosis,  nephritis, 
chlorosis  or  anaemia,  bad  surroundings,  and  exposure  ;  (3)  frequent 
parturition. 

II.  Exciting. — (1)  Immoderate  sexual  intercourse  ;  (2)  attempts 
to  prevent  conception  ;  (3)  intercourse  with  impotent  men ;  (4) 
masturbation  ;  (5)  extension  of  inflammation  from  vagina  or  body 
of  uterus  ;  (6)  stenosis  of  os  externum  ;  (7)  local  injuries,  mechani- 
cal and  chemical ;  (8)  labor  (laceration  and  subinvolution)  is  the 
most  common  cause  in  multiparae. 

What  is  the  normal  histology  of  the  cervix  ? 

There  is  no  serous  coat.  The  muscular  is  quite  subordinate  to 
the  connective  tissue,  and  does  not  form  layers.  Then  come  the 
mucous  membrane ;  a  submucous  layer,  which  does  not  exist  in 
the  body  of  the  uterus ;  and  the  parenchyma. 

The  mucous  membrane  is  paler  and  firmer  than  in  the  body.  It 
presents  anteriorly  and  posteriorly  an  arbor  vitae.  These  are  formed 
by  an  anterior  and  a  posterior  median  pillar  with  countless  lateral 
rugae,  and  these  and  the  grooves  between  them  are  still  further 
subdivided,  so  that  the  surface  presents  ever  so  many  minute 
depressions  or  crypts,  and  everywhere  there  are  seen  the  mouths 
of  the  glands,  which  number  about  ten  thousand.  The  glands  are 
simple,  tubular,  or  bottle-shaped,  or  compound  racemose,  and  open 
into  the  crypts.  The  Nahothian  glands  are  glands  of  any  of  the 
above  forms,  the  mouths  of  which  have  been  occluded  and  the 
secretion  retained.  The  glands  are  lined  by  cuboidal  epithelium. 
The  general  surface  is  covered   by  a  single  layer  of  cylindrical 


136  DISEASES   OF   THE   UTERUS. 

epithelium  which  is  ciliated  (in  the  depressions  only)  from  the 
internal  to  the  external  os.  It  is  continuous  with  that  lining  the 
glands,  and  at  the  external  os  changes  abruptly  to  flat  epithelium. 
The  vaginal  surface  of  the  cervix  is  covered  by  stratified  pavement 
epithelium,  beneath  which  there  are  papillae  and  no  glands ;  it  is 
thus  very  much  like  a  cutaneous  surface.  The  cervix  is  poorly 
supplied  with  spinal  nerves  (hence  is  relatively  insensible),  but 
richly  with  sympathetic  nerves. 

What  is  the  pathology? 

In  simple  recent  cases  the  mucous  membrane  is  congested,  thick- 
ened, and  softened.  There  is  increased  discharge.  In  old,  long- 
standing cases — (a)  There  is  a  iiroliferation  of  the  epitlielial  cells. 
This  is  always  in  a  single  layer,  and  results  in  an  increase  in  the 
surface  of  the  mucous  membrane  in  several  ways :  (1)  Chiefly  by 
the  cylindrical  displacing  the  flat  epithelium  on  the  vaginal  surface, 
thus  producing  "  erosions."  (2)  At  certain  points  on  the  vaginal 
surface  the  flat  epithelium  desquamates,  leaving  exposed  the 
cuboidal  epithelium  covering  the  papillae,  and  this  in  turn  changes 
to  cylindrical  epithelium.  The  surface  is  thrown  into  folds  sepa- 
rated by  deep  clefts,  forming  really  new  glands.  The  effect  of  all 
these  is  the  creation  of  a  large  additional  secreting  surface. 

(6)  The  glands  are  chiefly  occluded  (both  old  and  new  glands), 
and  the  contents  of  these  retention  cysts  may  be — 1,  ordinary 
secretion  ;  2,  pus  ;  3,  caseous  material ;  or,  4,  chalky  concretions. 
Each  one  is  about  the  size  of  a  pea,  and  may  extend  toward  the 
cervical  canal  or  toward  the  vaginal  surface,  where  are  normally 
no  glands,  and  there  form  knobs. 

Cystic  degeneration  of  the  cervix  is  the  name  given  to  those 
cases  in  which  such  occluded  glands  occupy  the  greater  part  of 
the  cervix,  including  its  vaginal  aspect. 

What  are  the  varieties  of  erosions  of  the  cervix  ? 

(1)  Simple  ;  (2)  papillary  ;   (3)  follicular. 

(1)  Simple  Erosions  are  bright-red  spots  on  the  vaginal  aspect 
of  the  cervix,  where  the  flat  epithelium  has  been  replaced  by 
cylindrical.  They  set  up  a  continuous  and  protracted  discharge, 
and  should  always  be  treated. 

(2)  Papillary  Erosions  diff'er  from  simple  erosions  only  in  the 
fact  that  the  mucous  membrane  is  furrowed  by  crypts  which  leave 
papilliform  eminences.     The  furrows  are  sometimes  so  deep  as  to 


CHRONIC   CERVICAL    ENDOMETRITIS.  137 

simulate  lacerations  of  the  cervix,  and  might  cause  unpleasant 
complications  in  the  case  of  an  unmarried  woman. 

(3)  F<jllicidar  Erosions  are  like  simple  erosions,  with  the  addi- 
tion of  retention  cysts,  some  of  which  may  have  ruptured. 

Coxcomb  GramdatAons  are  the  hypertrophic  folds  or  ridges  of 
the  cervical  mucous  membrane  which  occur  in  all  long-standing 
cases. 

What  are  the  symptoms  of  cervical  catarrh  ? 

(1)  Pain  is  not  a  prominent  symptom  :  it  is  often  wholly  absent. 
Later,  especially  with  hypertrophy,  there  is  dull  pain  in  the  back 
(lumbar  and  sacral)  and  pelvis.  With  retention  cysts  there  is  con- 
stant burning  pain  in  the  cervix. 

(2)  Dyspareunia  :  severe  itching  and  burning  follow  sexual  inter- 
course. 

(3)  Discharge  may  be  absent.  In  simple  cases  it  is  clear  and 
viscid  ;  in  old  cases,  turbid,  purulent,  and  more  viscid ;  in  the  worst 
cases  extremely  viscid  and  elastic. 

(4)  Sterility,  the  discharge  acting  as  a  mechanical  barrier. 

(5)  Dehility,  as  the  discharge  may  be  a  constant  drain  on  the 
system. 

(6)  Vesical  irritability. 

(7)  Constipation. 

(8)  Functioned  Disturbances :  (a)  Reflex  congestion  of  ovaries 
and  uterus  (menorrhagia  or  metrorrhagia)  ;  (i)  neuralgia,  head- 
ache, sometimes  hysteria. 

What  are  the  physical  signs? 

In  Virgins. — There  may  be  a  long,  narrow  cervix,  which  is  en- 
larged, sensitive,  and  succulent.  No  erosions.  On  dilating  the  os 
the  cervical  canal  is  found  dilated  and  filled  with  coxcomb  granu- 
lations. Abundant  discharge.  In  another  class  of  cases  the  os  is 
rather  wide,  and  there  are  large  papillary  erosions  which  resemble 
a  laceration  or  eversion  of  the  cervix. 

In  Multiparse.. — The  lips  of  the  cervix  are  usually  lacerated  and 
the  mucous  membrane  everted,  with  possibly  deep  clefts  and  the 
formation  of  cysts.     The  last  are  better  felt  than  seen. 

What  is  the  diagnosis? 

(From  catarrh  of  the  body  of  the  uterus.)  (1)  The  cervix  alone 
is  tender ;  (2)  presence  of  erosions  ;  (3)  thick  tenacious  discharge. 


138  DISEASES   OF   THE    UTERUS. 

What  is  the  course? 

Exceedingly  slow,  and  showing  no  tendency  toward  spontaneous 
recovery.  A  certain  number  of  cases  are  followed  by  carcinoma 
of  the  cervix.  It  is  often  impossible  to  distinguish  under  the 
microscope  between  an  erosion  which  is  healing  and  carcinoma. 

Is  the  prognosis  good? 

Yes,  if  the  case  is  properly  treated. 

What  is  the  treatment? 

It  may  be — («)  General. — Remove  the  regular  causes  ;  improve 
hygienic  conditions  ;  limit  sexual  intercourse  ;  regulate  the  bowels 
and  bladder ;  and  remedy  displacements  of  the  uterus.     Or 

(6)  Local. — 1.  For  Simple  Erosion. — (1)  Emollient  vaginal 
douches,  salt,  bran,  starch,  linseed  oil,  tincture  of  opium,  or  bella- 
donna in  warm  water.  (2)  Applications  :  the  best  is  pyroligneous 
acid,  poured  into  a  tubular  speculum,  so  as  to  bathe  the  cervix  for 
a  few  minutes.     This  is  done  three  times  a  week. 

2.  For  Papillary  Erosions. — Cut  them  away  with  scissors,  and 
treat  the  base  with  nitrate  of  silver  or  chromic  acid. 

3.  For  the  Cervical  Canal. — Best,  tincture  of  iodine,  or  Battey's 
solution  (carbolic  acid,  alum,  and  iodine),  or  nitrate  of  silver. 

4.  For  Cysts. — Puncture  them  from  the  vaginal  surface  with  a 
Buttle's  spear  or  a  tenotomy  knife,  and  then  bore  into  them  with 
the  solid  stick  of  nitrate  of  silver. 

5.  For  Cases  requiring  Removal  of  the  entire  Mucous  Memhrane. — 
(1)  Caustics. — Clean  away  the  secretion  (best,  a  probe  with  cotton 
powdered  with  alum  and  used  with  a  twisting  motion).  Introduce 
an  applicator  covered  with  cotton  soaked  in  fuming  nitric  acid  or 
W'ith  chromic  acid.  The  applicator  is  left  in  until  it  dries.  Later, 
repeated  applications  of  nitrate  of  silver  solution  or  of  tincture  of 
iodine  are  made  to  prevent  exuberant  granulations.  (2)  Surgical 
Measures. — Several  longitudinal  incisions  are  made  through  the 
mucous  membrane,  and  two  or  three  days  later  the  entire  cervical 
mucous  membrane  is  scraped  out  with  a  sharp  spoon.  Pack  a  lit- 
tle iodoform  gauze  into  the  cervix,  and  introduce  a  vaginal  tampon. 
This  cures  all  cases  except  those  with  extensive  cystic  degenera- 
tion, and  is  more  desirable  than  the  use  of  caustics,  which  is  often 
followed  by  cicatricial  stenosis.  It  can  be  done  in  the  office  or 
dispensary.  (Of  course  the  after-treatment  consists  in  alterative 
applications  to  prevent  excessive  growth  of  the  mucous  membrane.) 


LACERATION    OF   THE   CERVIX. 


139 


6.  For  an  Extensive  Laceration. — Emmet's  operation. 

7.  For  Great  Cystic  Degeneration. — Schroeder's  operation.     By 
this   method   cases   can   be   cured  which  are  otherwise  incurable. 

Fig.  64. 


Schroeder's  Operation. 

Its  only  disadvantage  is  that  it  leaves   the  cervix   shorter  than 
normal. 


LACERATION  OF  THE  CERVIX. 
What  is  its  occurrence? 

It  constitutes  32.8  per  cent,  of  all  gynecological  cases.  Perhaps 
some  laceration  always  occurs  during  parturition,  but  in  most  cases 
it  is  slight,  is  not  recognized  at  the  time,  and  heals  readily.  It 
occurs  in  all  stations  of  life,  but  in  instrumental  cases  it  is  more 
frequent  among  the  poor. 

What  are  its  causes? 

(1)  Labor. — Tedious,  most  frequent ;  precipitate  ;  instrumental ; 
manual  delivery  ;  rigid  os  and  premature  rupture  of  membranes  ; 
cicatricial  or  malignant  tissue  in  cervix  :  incision  of  cervix  for  fail- 
ure to  dilate. 

(2)  Abortion. — Criminal. 

What  are  its  varieties  ? 

Complete,  partial,  unilateral,  bilateral,  stellate. 
A  partial  laceration  extends  only  through  the  mucous  and  sub- 
mucous layers,  and  leaves  the  vaginal  surface  intact. 


140 


DISEASES   OF   THE   UTERUS. 


What  is  its  site  ? 

Most  frequently  through  the  anterior  lip  a  little  to  the  left,  due 
to  pressure  by  the  occiput  in  the  first  position. 

Next  in  frequency,  double,  anterior  lip  to  the  left  and  posterior 
lip  to  the  right ;  bilateral  ;  stellate ;  unilateral,  more  often  to 
the  left. 

(1)  Laceration  of  the  anterior  lip  usually  heals  readily,  because, 
as  a  rule,  it  does  not  extend  into  the  pelvic  connective  tissue.  If 
it  does  so,  we  may  have  vesico-cervical  fistula. 

(2)  Laceration  of  the  posterior  lip  as  a  rule  heals  readily,  but 
it  may  extend  into  the  connective  tissue  and  produce  cellulitis  in 
one  of  the  utero-sacral  ligaments,  resulting  in  contraction  of  the 
ligament  and  displacement  of  the  uterus. 

(3)  Bilateral  laceration  constitutes  the  great  bulk  of  the  cases 
requiring  treatment.     It  is  very  apt  to  extend  into  the  connective 

Fig.  65. 


Multiple  or  Stellate  Laceration  of  the  Cervix  (Kmmet). 


tissue  of  the  broad  ligaments,  and  we  have  cellulitis,  interference 
with  the  circulation,  causing  ectropion,  or,  starting  from  the  bottom 
of  the  tear,  erosions  of  the  cervix,  subinvolution,  and  prolapse  (es- 
pecially if  the  perineum  is  lacerated),  and  retroversion,  catarrh, 
cystic  degeneration,  and  a  cicatricial  plug  are  produced.     The  latter 


LACERATION   OF   THE   CERVIX. 


141 


is  a  dense  mass  of  cicatricial  tissue  formed  at  the  deepest  angle 
of  the  laceration  by  an  incomplete  attempt  at  healing  by  granula- 
tion. This  tissue  must  be  removed  in  any  operation  for  repairing 
the  laceration. 

(4)  Stellate  laceration  is  usually  superficial,  and  produces,  as  a 
rule,  none  of  the  special  symptoms  of  laceration.  There  is  no 
sterility,  but,  on  the  contrary,  often  unusual  fecundity. 

(5)  Unilateral  laceration  does  not  produce  the  characteristic 
symptoms.  The  whole  uterus  is  bent  toward  the  injured  side  (con- 
traction of  ligaments  consequent  upon  cellulitis) ;  the  anterior  for- 

FiG.  66. 


Double  Tenaculum  separating  the  Flaps  of  a  [Unilateral]  Laceration  (Emmet) 

nix  is  as  deep  as  the  posterior.     The  uterine  cavity  may  be  appar- 
ently of  the  normal  length. 

(6)  Partial  laceration  is  about  half  a  dozen  longitudinal  fissures 
through  the  mucous  and  submucous  layers  of  the  wall  of  the  cer- 
vical canal.  This  sets  up  catarrh,  and  the  cervix  is  somewhat  en- 
larged, but  its  walls  are  thinner  than  normal.  (This  condition 
must  be  distinguished  from  the  ridges  and  grooves  produced  by 
chronic  cervical  catarrh  with  coxcomb  granulations.) 

What  are  the  symptoms  of  laceration  of  the  cervix  ? 

(1)  Pain,  lumbar  and  sacral ;  a  dragging  pain  in  the  groins,  and 
a  bearing-down  pain.  All  are  increased  by  any  efifort,  such  as 
standing  or  walking. 

(2)  Vesical  Irritability^  very  frequent  micturition. 


142  DISEASES   OF   THE   UTERUS. 

(3)  Dyspareunia,  and  sometimes  hemorrhage  after  intercourse. 

(4)  Leucorrhcea,  profuse  and  constant. 

(5)  Menstruation  is  at  first  simply  profuse  ;  later  it  is  irregular 
as  to  time,  and  usually  profuse,  but  may  be  scanty. 

(6)  Sterility.     Later  symptoms  : 

(7)  Anaemia  and  headaches  (occipital  and  at  the  nape  of  the 
neck). 

(8)  Neuralgiae,  insomnia,  change  of  temperament,  melancholia. 

What  are  the  physical  signs? 

Digital  examination  is  unreliable.  Bivalve  speculum  and  a 
tenaculum  in  each  lip  give  ocular  demonstration  of  the  laceration. 
(It  is  sometimes  impossible  for  a  number  of  weeks  after  labor  to 
determine  whether  there  is  a  laceration  of  the  cervix.) 

What  are  the  complications? 

(1)  Chronic  pelvic  cellulitis ;  (2)  chronic  endometritis  (com- 
monly fungoid)  ;  (3)  chronic  cervical  catarrh,  with  erosions  and 
cystic  degeneration  of  the  cervix,  and  sterility  ;  (4)  hypertrophy 
of  the  cervix  or  of  the  entire  uterus ;  subinvolution  ;  chronic 
metritis  ;  (5)  displacements  of  the  uterus  ;  (G)  tendency  to  abor- 
tion. 

What  is  the  prognosis? 

If  untreated,  a  recent  laceration  may  exceptionally  cicatrize  and 
the  symptoms  disappear  ;  but,  as  a  rule,  the  patients  are  invalids 
until  radical  treatment  is  resorted  to.  Cases  operated  upon,  as  a 
rule,  are  cured  of  all  symptoms. 

What  is  the  treatment? 

(1)  General;  (2)  preparatory  ;  (3)  operative. 

(1)  General  Treatment. — a,  Remove  pressure  from  above  (skirts, 
corsets,  etc.)  ;  5,  a  pessary  is  often  indicated  ;  c,  tonics. 

(2)  Preparatory  Treatment. — To  lessen  local  congestion  and  to 
cure  catarrh,  erosions,  and  cysts — «,  emollient  vaginal  douches  ; 
/>,  scarification  (once  or  twice  weekly)  ;  c,  puncture  of  cysts  and 
touching  their  cavity  with  nitric  or  chromic  acid  ;  cZ,  erasion  of 
mucous  membrane  and  alterative  applications ;  in  mild  cases  Church- 
ill's tincture  without  the  curetting  ;  e,  glycerin  tampons  ;  /,  if  the 
flaps  are  very  large  and  very  far  apart,  a  single  silver  suture  may 
be  introduced  one  or  two  weeks  before  the  operation. 

(3)  Operative  Treatment. — The  results  of  operations  performed 
immediately  after  labor  are  very  unsatisfactory.    If  profuse  hemor- 


LACERATION   OF   THE   CERVIX. 


143 


rhage  occur  from  a  laceration,  it  may  be  controlled  by  one  or  two 
silver  sutures,  but  a  formal  operation  had  better  not  be  attempted 
for  a  number  of  months. 

Describe  Emmet's  operation  for  trachelorrhaphy. 

It  is  the  best  operation  for  the  repair  of  a  laceration  of  the 
cervix,  and  depends  for  its  success  upon  asepsis  and  perfect  apposi- 


FiG.  68. 


Insertion  of  Sutures 


Sutures  in  Place. 


tion  of  denuded  surfaces,  so  that  no  point  of  granulation  is  left. 
It  is  usually,  but  not  necessarily,  done  under  anaesthesia.  The 
bladder  and  rectum  should  be  empty  and  the  vagina  disinfected. 
Three  assistants  are  necessary,  and  the  operation  should  never  be 
done  when  there  is  cellulitis,  as  indicated  by  tenderness. 

The  patient  is  in  Sims's  position,  and  the  uterus  is  drawn  down 
by  two  silk  sutures,  one  passed  through  each  lip  of  the  cervix. 
In  denuding  the  flaps  begin  at  the  lower  part  of  the  lower  right- 
hand  flap,  and  cut  parallel  with  its  surface  up  to  the  angle.  Then 
the  upper  right-hand  flap  is  similarly  pared.  If  a  nodular  mass 
("  cicatricial  "plug ")  can  now  be  felt  at  the  angle,  it  must  be 
excised. 


144 


DISEASES   OF   THE   UTERUS. 
Fig.  69. 


Position  of  Patient  in  Emmet's  Trachelorrhaphy. 

The  left-hand  flap  is  similarly  treated.  (Gynecologists  use  scis- 
sors, Emmet's  curved,  but  it  can  be  done  with  a  scalpel.)  Hemor- 
rhage is  controlled  by  pressure  or  by  hot  antiseptic  irrigation. 

In  suturing^  Emmet's  short  cervical  needle,  threaded  with  a  loop 

Fig.  70. 


Area  of  Denudation  in  Trachelorrhaphy. 


LACERATION   OF   THE   CERVIX. 


145 


of  silk  to  carry  a  silver  suture  eight  or  ten  inches  long,  is  used. 
Three  or  four  sutures  are  introduced  at  each  side,  beginning  close 


Fig.  71. 


Lacerated  Cervix  after  Denudation. 


to  the  angle,  and  they  are  tightened  in  the  same  order  by  means 
of  a  wire-twister  and  shield.  The  ends  are  bent  flat  against  the 
cervix,  and  the  vagina  is  lightly  tamponed. 

The  patient  is  kept  in  bed  two  weeks  (urination  and  defecation 


10— Gyn. 


Fig.  72. 


Schultze's  Dilator. 


146  NEOPLASMS  OF  THE  UTERUS. 

in  the  recumbent  position).  Antiseptic  vaginal  douches  every  two 
or  three  days.  The  sutures  are  removed  on  the  ninth  day,  and  in 
the  order  in  which  they  were  introduced. 

NEOPLASMS  OF  THE  UTERUS. 

Describe  their  occurrence. 

They  are  more  frequent  and  more  varied  than  in  any  other  organ. 
This  is  due  to  the  complexity  of  its  structure.  Congenital  tumors 
of  the  uterus  are  almost  unknown.  It  is  doubtful  also  whether 
uterine  tumors  ever  occur  before  puberty. 

What  is  the  classification  ? 

I.  Tumors  arising  from  the  parenchyma  (i.  e.  muscular  or  con- 
nective tissue)  of  the  uterus :  fibromyoma  (benign)  ;  sarcoma  (ma- 
lignant). 

II.  Tumors  arising  from  the  mucous  membrane :  mucous  polypi 
(benign);  carcinoma  (malignant)  ;  adenoma  (doubtful). 

FIBROID   TUMORS,  OR  FIBROMYOMATA. 

Describe  their  occurrence. 

They  are  the  most  common  of  uterine  tumors.  Half  of  all 
women  over  fifty  have  been  said  to  have  them,  but  this  is  an 
exaggeration  (Tuttle). 

What  is  the  etiology? 

Race. — African  (nearly  all  who  have  any  uterine  trouble  have 
them). 

Age. — Thirty  to  forty  (never  before  puberty,  and  never  originate 
after  the  menopause). 

(The  influence  of  marriage  and  parturition  is  unknown.  Sterility 
is  a  result,  not  a  cause.) 

What  is  the  pathology  ? 

They  all  consist  of  hypertrophic  muscular  fibres  and  of  connec- 
tive tissue,  and  hence  are  all  called  fibromyomata.  In  the  great 
majority  of  cases  the  connective  tissue  is  so  much  in  excess  that 
the  tumor  may  be  considered  a  fibroma. 

Fibroma  feels  and  cuts  hard.  The  cut  surface  is  white,  and 
presents  even  to  the  naked  eye  bundles  of  connective  tissue  ar- 
ranged about  various  centres.  There  is  a  distinct  capsule  of  loose, 
highly  vascular  connective  tissue.     As  to  site,  it  is  most  frequent 


NEOPLASMS  OF  THE  UTERUS.  147 

in  the  body  of  the  uterus  (in  its  posterior  or  anterior  wall,  rarely 
at  the  sides). 

Myoma  is  soft,  red,  and  succulent ;  it  consists  chiefly  of  muscu- 
lar fibres,  and  may  be  considered  a  local  hypertrophy  of  the  uterine 
wall.  Microscopically  the  muscular  fibres  are  seen  to  be  enor- 
mously hypertrophied,  as  in  the  pregnant  uterus.  It  is  most  com- 
monly found  near  the  fundus. 

What  are  the  varieties? 

(1)  Subserous  or  subperitoneal ;  (2)  interstitial  (intramural,  in- 
traparietal)  ;  (3)  submucous. 

SUBSEROUS  FIBROIDS. 

These  begin  in  the  muscular  wall  near  the  outer  surface,  and 
grow  in  the  direction  of  least  resistance.     The  most  common  site 

Fig.  73. 


Subserous  Fibroid  of  Uterus. 

is  the  posterior  wall,  less  common  the  anterior  wall.  They  are 
usually  multiple,  but  the  others  are  apt  to  be  interstitial  or  submu- 
cous. They  may  be  simple  or  compound,  and  may  have  a  long, 
narrow  or  a  short,  broad  pedicle.  A  large  fibroid  with  a  thick 
pedicle  may  draw  the  uterus  up,  and  even  stretch  it.  They  most 
often  grow  into  Douglas's  pouch  and  drag  the  uterus  back.  A 
fibroid,  especially  one  with  a  long  pedicle,  may  become  incarcerated 
in  Douglas's  pouch.  Adhesions  may  be  excited  by  the  movements 
of  the  tumor,  and  the  tumor  become  attached  to  the  bladder,  rec- 
tum, or  abdominal  wall.  The  pedicle  in  some  cases  is  so  stretched 
as  to  give  way,  and  the  fibroid  become  an  independent  tumor.     If 


148 


FIBROIDS   OF    THE    UTERUS. 


the  vascular  supply  from  the  adhesions  is  sufficiently  free,  we  may 
find  the  tumor  increasing  in  size  in  its  new  situation. 

INTERSTITIAL  FIBROIDS. 

These  begin  deeply  in  the  muscular  wall,  and  develop  equally  in 
all  directions  until  finally  a  bulging  of  both  external  and  internal 

Fig.  74. 


Interstitial  Fibroid. 

surfaces  is  produced.  The  tumor  is  surrounded  by  normal  uterine 
tissue ;  it  is  usually  multiple,  may  be  simple  or  compound,  most 
common  near  the  fundus,  and  consists  principally  of  muscular 
fibres. 

SUBMUCOUS  FIBROIDS. 

Beginning  in  the  layer  of  muscular  tissue  immediately  beneath 
the  mucous  membrane  and  protruding  into  the  uterine  cavity,  these 
have  usually  a  broad,  thick  pedicle,  but  may  have  a  long,  thin  pedi- 
cle, in  which  case  they  are  called  fibrous  polypi. 

What  are  the  complications  of  fibroid  tumors  ? 

A.   Changes  in  structure   of  the  uterus:   (1)  The  whole  uterus 


NEOPLASMS   OF   THE   UTERUS. 


149 


may  be  hypertropliied,  its  walls  thickened,  and  its  cavity  increased 
in  size  and  length.  (This  is  often  the  case  with  submucous  and 
interstitial  fibroids.)      (2)   Chronic   endometritis,  with   thickening 

Fig.  75. 


Submucous  Fibroid. 


of  the  mucous  membrane  and  increase  in  the  glands,  except  over 
the  tumor,  where  the  membrane  is  atrophic. 

B.  Changes  in  the  position  of  the  uterus :  (1)  Ascent — the  ute- 
rus may  be  stretched  until  it  measures  six  or  eight  inches.  (2) 
Prolapse.  (3)  Inversion  (can  occur  only  with  a  submucous  polypus 
with  a  short  pedicle).  (4)  Retroflexion  or  anteflexion.  (5)  Incar- 
ceration of  the  uterus  (by  a  tumor  in  Douglas's  cul-de-sac,  fixed  by 
adhesions  and  continuing  to  increase  in  size). 

C.  Degeneration  in  the  tumor.  (1)  Softening.  (2)  Induration 
(as  a  rule,  after  the  climacteric).  (3)  Calcification  (occurs  about 
the  climacteric).     (4)  Suppuration  and  gangrene  (usually  the  result 


150 


FIBROIDS   OF   THE    UTERUS. 


of  violence  in  examination  or  treatment).  (5)  Sarcomatous  degene- 
ration is  well  proven  to  occur.  (G)  Carcinomatous  degeneration 
probably  never  occurs. 

What  are  the  special  features  of  fibroids  of  the  cervix  ? 

Subperitoneal  Fibroids  are  the  most  important.     They  start  be- 

FiG.  76. 


Fibroid  Incarcerated  in  the  Pelvis. 


hind  and  to  one  side,  and  grow  either  (1)  out  behind  the  layers 
of  the  broad  ligament,  tending  to  fill  up  the  pelvis ;  or  (2)  down- 


NEOPLASMS  OF  THE  UTERUS.  151 

ward  into  the  connective  tissue  alongside  the  vagina.  Pathology. — 
Almost  exclusively  connective  tissue.  They  have  a  short,  broad 
pedicle,  and  are  rather  fixed.  Dangers. — They  cannot  rise  out  of 
the  pelvis,  and  as  they  grow  they  become  incarcerated  and  press 
upon  nerve  and  other  structures.  It  is  sometimes  impossible  to 
remove  them. 

Submucous  and  Interstitial  Fibroids  give  rise  to  distortion  of  the 
cervix,  and  are  rather  difficult  to  diagnose. 

What  are  the  symptoms  of  fibroid  tumors  ? 
I.  Hemorrhage  ; 
II.  Pain; 
III.  Sterility. 

I.  Hemorrhage. — At  first  there  is  menorrhagia,  the  duration  of 
the  menstrual  flow  increasing  until  it  lasts  three  weeks  out  of 
every  four.  There  is  no  sudden  flooding,  but  an  insidious  loss  of 
blood.  The  blood  comes  not  from  the  tumor,  nor  from  the  thin 
atrophic  mucous  membrane  over  it,  but  from  the  rest  of  the  mucous 
membrane.  Later,  there  is  added  metrorrhagia.  The  mucous 
membrane  over  the  tumor  becomes  ulcerated,  and  the  vascular 
capsule  of  the  tumor  is  exposed.  From  this  there  is  irregular 
hemorrhage  excited  by  any  muscular  efi"ort  or  misstep,  etc.  There 
is  always  hemorrhage  in  the  submucous,  often  in  the  interstitial, 
but  not  so  commonly  in  the  subserous,  varieties. 

II.  Pain. — In  submucous  fibroids  it  is  worst  at  menstruation 
from  engorgement  of  the  tumor,  which  also  acts  as  a  foreign  body 
and  produces  the  colicky  pains  of  obstructive  dysmenorrhoea. 

In  interstitial  fibroids  there  may  be  colicky  pain,  but  more  often 
it  is  a  tearing  or  stretching  pain  during  menstruation,  from  the 
pressure  of  the  engorged  tumor  upon  the  nerves  of  the  uterus. 

In  subserous  fibroids  there  is  a  sensation  of  dragging  and 
weight,  especially  during  menstruation.  There  are  also  attacks 
of  peritonitic  pain  (with  fever  and  tenderness,  indicating  local 
peritonitis). 

III.  Sterility  may  be  the  mechanical  efi^ect  of  a  large  tumor,  or 
it  may  be  due  to  the  complication,  chronic  endometritis. 

There  may  be  Symptoms  due  to  Pressure. 

On  the  Urethra. — Partial  or  complete  retention  of  urine. 
On  the  Bladder. — Vesical  irritability ;  sometimes  residual  urine 
and  cystitis. 


152  FIBROIDS   OF   THE   UTERUS. 

On  the  Ureters. — Partial  obstruction  or  hydronephrosis  and 
death. 

On  the  Rectum. — Constipation  or  faecal  obstruction. 

On  Nerves. — Sciatica,  numbness  of  the  limbs,  pain  in  the  joints. 

On  Vessels. — Haemorrhoids,  varicosities  of  labia  and  legs. 

What  secondary  symptoms  are  sometimes  present? 

Abortion  ;  leucorrhoea  (not  a  prominent  symptom)  ;  ascites,  rare 
(if  present  it  throws  doubt  upon  the  diagnosis)  ;  symptoms  of  early 
pregnancy. 

What  are  the  physical  signs  of  small  fibroid  tumors  ? 

(1)  In  the  case  of  a  small  fibroid  of  the  cervix  (which  would 
have  to  be  difierentiated  from  inversion  of  the  uterus)  find  the  os 
externum,  pass  a  sound,  and  by  bimanual  examination  (under 
anaesthesia  if  necessary)  determine  the  presence  of  the  fundus  of 
the  uterus  in  its  normal  place. 

(2)  With  a  small  pedunculated  submucous  fibroid  dilate  the 
cervix  and  introduce  the  finger. 

(3)  With  a  submucous  fibroid  with  a  broad  base  and  high  up  in 
the  fundus,  bimanual  examination  shows  the  uterus  to  be  enlarged. 
The  sound  may  pass  farther  than  the  normal.  Pass  a  finger  into 
the  anterior  fornix,  and  judge  of  the  amount  of  tissue  between  the 
finger  and  the  sound,  and  also  whether  there  is  any  localized  hard- 
ness. The  posterior  wall  of  the  uterus  is  examined  in  the  same 
way. 

What  is  the  differential  diagnosis  of  small  fibroid  tumors  ? 

(1)  Chronic  metritis ;  (2)  early  pregnancy ;  (3)  anteflexion ; 
(4)  retroflexion  ;  (5)  inversion  (which  see). 

(1)  Chronic  metritis  is  characterized  by  uniform  enlargement  of 
the  uterus,  absence  of  a  hard  lump,  sensitiveness. 

(2)  Early  pregnancy  :  With  fibroids  the  uterus  is  enlarged,  but 
hard.  In  early  pregnancy  the  uterus  is  enlarged,  but  soft  and 
elastic,  the  os  is  velvety,  and  menstruation  is  arrested.  (In  case 
of  doubt  wait  a  month  and  note  changes.) 

(3)  and  (4)  Flexions :  A  sound  with  the  necessary  curve  and 
a  finger  in  the  fornix  of  the  vagina  show  that  the  uterine  wall  is 
of  normal  thickness  throughout.  (In  the  case  of  a  fibroid  the 
uterine  canal  is  straight,  and  there  is  a  localized  thickening  and 
induration  of  the  uterine  wall.) 


NEOPLASMS  OF  THE  UTERUS.  153 

What  are  the  physical  signs  of  large  fibroid  tumors  ? 

(1)  Palpation. — a,  Outline  distinct,  consistence  hard  ;  6,  relation 
to  uterus.  An  assistant  pulls  down  the  uterus  with  the  volsella  ; 
you  feel  the  tumor  through  the  abdominal  wall ;  c,  position  usually 
near  median  line. 

(2)  Percussion. — Usually  flat,  but  may  be  dull-tympanitic  if 
covered  by  intestines. 

(3)  Auscultation. — A  souffle  may  be  heard,  most  often  over  the 
sides,  but  sometimes  over  the  entire  surface  of  the  tumor.  It  is 
only  present  when  large  vessels  enter  the  tumor. 

(4)  Vaginal  Touch. — (a)  The  cervix  is  hard ;  (6)  the  cervix  is 
drawn  up. 

(5)  Bimanual  Examination. — Grives  the  impression  of  a  mass 
belonging  to  the  uterus. 

(6)  Sound. — Never  use  it  unless  you  have  excluded  pregnancy, 
and  remember  that  pregnancy  and  fibroids  may  coexist,  (a)  The 
uterine  cavity  is  increased  in  length.  This  is  most  marked  with 
submucous  fibroids,  where  it  may  be  over  four  inches  long. 
(6)  The  uterine  cavity  may  be  tortuous  and  require  several  at- 
tempts before  the  sound  is  passed  quite  to  the  fundus. 

What  is  the  differential  diagnosis  of  large  fibroid  tumors  ? 

(1)  From  late  pregnancy;  (2)  ovarian  tumor;  (3)  extra-uterine 
pregnancy  ;  (4)  haematocele  and  inflammatory  exudation. 

(1)  From  Late  Pregnancy. — Symptoms  common  to  each  are — 
1,  abdominal  enlargement ;  2,  enlargement  and  pigmentation  of  the 
breasts ;  3,  violet  coloration  of  the  vaginal  mucous  membrane ; 
4,  uterine  souffle  ;  5,  morning  vomiting. 

The  symptoms  peculiar  to  pregnancy  are — 1,  the  foetal  heart- 
sounds  ;  2,  foetal  movements  ;  3,  ballottement ;  4,  rhythmic  contrac- 
tion of  the  uterus ;  5,  softening  of  the  cervix  ;  6,  arrest  of  men- 
struation. 

(2)  From  Ovarian  Tumor. — 1,  Ovarian  tumors  grow  rapidly; 
fibroids  slowly ;  2,  ovarian  tumors  begin  at  one  side ;  uterine 
fibroids  near  the  median  line  ;  3,  on  palpation  an  ovarian  tumor 
feels  soft  and  doughy  ;  fibroids  hard  and  well  defined  ;  4,  with  an 
ovarian  tumor  the  uterus  lies  low  down  in  front  of  or  behind  the 
tumor ;  with  fibroids  the  uterus  is  drawn  up  ;  5,  an  ovarian  tumor 
does  not  move  with  the  uterus  ;  a  fibroid  does  ;  6,  with  an  ovarian 
tumor  neither  the  uterus  nor  its  canal  is  enlarged  ;  both  are  with 
fibroids ;   7,  with  an  ovarian  tumor  there  is   often  irreo;ular  and 


154  FIBROIDS    OF    THE    UTERUS. 

painful  menstruation,  but  not  the  menorrhagia  and  metrorrhagia 
characteristic  of  fibroids. 

(3)  From  Extra-uterine  Pregnancy. — Common  to  both  are — 1, 
abdominal  tumor ;  2,  enlargement  and  pigmentation  of  the  breast : 
3,  morning  vomiting :  4,  uterine  souffle  :  5,  violet  coloration  of 
vagina  ;  G,  irregular  and  profuse  menstruation  ;  7,  attacks  of  peri- 
tonic  pain. 

Peculiar  to  extra-uterine  pregnancy. — 1,  rapid  growth  and  lateral 
position  of  the  tumor ;  2,  the  uterus  does  not  move  with  it ;  3, 
shreds  of  membrane  (characteristic  under  the  microscope)  are  oc- 
casionally cast  out  of  the  uterine  cavity. 

(4)  From  Hsematocele  or  Injiammatory  Exudation. — The  history 
is  characteristic  :  sudden  onset  with  fever,  pain,  and  tenderness,  and 
the  tumor  is  at  first  soft  and  diffuse  ;  later  it  contracts  and  be- 
comes hard,  but  always  remains  tender. 

What  is  the  course? 

(1)  As  a  rule,  the  growth  is  arrested  at  the  menopause.  It  may 
then  become  indurated  or  calcified,  and  sometimes  reduced  in  size. 
The  cause  is  the  diminution  in  vascularity.  (2)  The  same  change 
may  take  place  in  younger  women  in  whom  from  any  cause  the 
sexual  functions  cease. 

How  may  spontaneous  cure  occur  in  fibroids? 

(1)  Expulsion  by  uterine  contractions  ;  (2)  rupture  of  pedicle  (if 
submucous  or  subserous)  ;  (3)  spontaneous  enucleation  (the  capsule 
ulcerates  through,  and  the  tumor  is  drawn  out  by  uterine  contrac- 
tions) ;  (4)  suppuration  and  gangrene  of  the  tumor  itself,  and  dis- 
charge piecemeal  (commonly  by  the  vagina,  rarely  by  rectum  or  blad- 
der) :  this  is  very  often  associated  with  fatal  septic  intoxication. 

What  are  the  causes  of  death  ? 

Hemorrhage,  rarely ;  exhaustion  from  long-continued  drain  ; 
peritonitis,  rarely  ;  septic  peritonitis  ;  rarely  pressure  on  ureters,  etc. 

What  is  the  prognosis? 

Good.     Recurrence  never  takes  place  ;  they  are  benign. 

Describe  the  treatment. 

It  may  be  general,  or  local  by  electrolysis,  surgical  removal,  re- 
moval of  uterine  appendages. 

Describe  the  general  treatment. 

Give  tonics  and  prevent  incarceration.     Keep  the  tumor  out  of 


NEOPLASMS  OF  THE  UTERUS.  155 

the  pelvis,  and  if  large  apply  an  abdominal  bandage  to  support  it. 
Bromide  of  potash  probably  has  no  effect,  and  the  same  is  true  of 
iodide  of  potash,  the  salts  of  zinc,  and  arsenic  and  phosphorus 
(Tuttle).  All  of  the  above  have  been  recommended  at  different 
times.  Ergot  acts  in  two  ways  :  it  causes  contraction  of  the  arte- 
rioles themselves,  and  causes  contraction  of  the  uterine  muscular 
fibres,  further  narrowing  the  vessels  and  tending  to  expel  the  tumor. 
For  administration  Squibbs'  ergotin  is  given  hypodermically. 
Ten  minims  of  the  following  formula  may  be  deeply  injected  in 
the  abdominal  wall,  the  thigh,  or  the  buttock  : 

K{.  Ergotin  (Squibbs'),  ^ij  ; 

Chloral  hydrate,  ^ss  ; 

Aquae,  q.  s.  ad  gj. — M, 

The  effect  is  visible  after  fifty  or  one  hundred  injections,  and  the 
best  cases  are  interstitial  fibroids,  which  may  be  positively  cured. 
It  is  useless  in  submucous  or  subserous  fibroids. 

Describe  the  local  treatment  by  electrolysis. 

This  method  of  treatment  was  proposed  by  Apostoli  of  Paris, 
but  has  not  yet  been  generally  adopted.  The  best  battery  is  one 
in  which  the  elements  are  about  thirty  plates  of  copper  and  zinc, 
6  by  9  inches,  in  a  solution  of  chromate  of  potash.  Insulated  con- 
ducting wires  and  silver  intra-uterine  probes,  with  a  groove  to  en- 
sure'the  patency  of  the  os,  and  a  broad  sponge  electrode  for  the 
surface  of  the  abdomen,  are  the  apparatus  required.  No  anaes- 
thetic is  needed.  The  current  of  50  to  150  milliamperes  should  be 
allowed  to  flow  for  three  to  fifteen  minutes,  according  to  symptoms. 
Galvano-puncture  if  the  tumor  is  felt  in  Douglas'  pouch.  The 
after-treatment  is  rest  in  bed  and  morphine  if  required.  The  re- 
sults claimed  for  it  are — 50  per  cent,  arrested ;  40  per  cent, 
benefited  ;  8  per  cent,  not  benefited ;  2  per  cent,  deaths. 

The  dangers  of  this  method  of  treatment  are — puncturing  the 
intestines ;  exciting  suppuration  and  gangrene  in  the  tumor,  with 
the  risk  of  septic  peritonitis,  etc. ;  hemorrhage  and  collapse. 

Describe  the  local  treatment  by  surgical  removal. 

I.  Removal  hy  the  Vagina  (submucous  or  interstitial  fibroids). — 
(1)  Dilate  the  cervix  (after  making  two  superficial  lateral  incisions) 
until  it  is  large  enough  to  permit  the  extrusion  of  the  tumor.  (2) 
Make  a  crucial  incision  1  inch  long  and  \  inch  deep  over  the  most 


156  FIBROIDS   OF   THE   UTERUS. 

dependent  portion  of  the  tumor.  (3)  Give  ergot  systematically, 
and  finally,  as  a  rule,  the  tumor  will  be  expelled  spontaneously. 
(-4)  If  necessary  enucleate  the  tumor  at  once  with  a  spoon-saw 
and  volsella,  finally  cutting  the  pedicle  with  the  scissors.  The  ope- 
ration should  be  done  under  ether  and  all  antiseptic  precautions 
observed. 

II.  Removal  hy  Ahdominal  Section. — The  mortality  is  very  great 
all  over  the  world  (50  per  cent.,  which  is  very  much  greater  than 
that  of  ovariotomy),  but  in  the  hands  of  some  operators  it  is  small 
(8  per  cent.). 

Mteps  of  the  Operation. — (1)  Anaesthesia  and  usual  antisepsis; 
incision  four  or  five  inches  long  in  the  median  line.  (2)  Bringing 
the  tumor  out  through  the  incision.  (3)  Treatment  of  the  stump  : 
(a)  intraperitoneal  method;  (h)  extraperitoneal  method. 

(a)  Intraperitoneal  Method. — This  is  applicable,  first,  to  tumors 
with  small  pedicles,  which  are  simply  ligated,  dropped  back  into 
the  abdominal  cavity,  and  the  abdominal  wound  accurately  sutured 
throughout.  (The  results  are  very  good  indeed,  but  these  are 
tumors  which  do  not  ordinarily  require  operation.  Indications  for 
operating  upon  such  a  tumor  would  be — 1,  hemorrhage  uncontroll- 
able in  any  other  way,  and  where  we  cannot  remove  the  appen- 
dages ;  2,  continuance  of  growth  in  the  tumor  after  the  meno- 
pause ;  3,  extreme  size  of  tumor  rendering  life  a  burden ;  4,  rarely 
recurrent  ascites.) 

The  intraperitoneal  method  is  applicable,  second,  to  tumors  with 
short,  broad  bases,  and  is  as  follows :  An  elastic  ligature  is  passed 
around  the  uterus  at  the  level  of  the  os  internum  ;  the  tumor  is 
removed  by  a  V-shaped  incision  into  the  substance  of  the  uterus ; 
this  incision  is  closed  by  muscular  and  j^eritoneal  sutures  (none 
passing  through  the  mucous  membrane)  ;  the  uterus  is  dropped  back 
into  the  pelvis,  and  the  abdominal  wound  accurately  closed.  (The 
dangers  of  this  method  are — 1,  hemorrhage;  2,  peritonitis;  3,  sep- 
tic infection  from  opening  the  intra-uterine  canal.  If  this  has  been 
opened,  it  must  be  accurately  closed  by  suture,  first  of  the  mucous 
membrane,  then  of  the  muscular  wall,  and  then  of  the  peritoneum.) 
The  results  are  less  satisfactory  than  those  of  the  extraperitoneal 
method. 

Schroeder^ s  Modification  of  the  Intraperitoneal  Method  consists 
in  passing  a  double  ligature  through  the  cervix,  tying  off  the  ap- 
pendages, cutting  away  the  uterus,  and  suturing  the  peritoneum 
over  the  stump.     The  stump  is  left  free  in  the  peritoneal  cavity. 


NEOPLASMS  OF  THE  UTERUS.  157 

The  abdominal  wound  is  sutured.  The  vagina  and  uterine  canal 
are  disinfected  before  operation,  and  drainage  is  provided  after  ope- 
ration by  a  strip  of  iodoform  gauze  passing  into  the  uterine  canal 
from   the  vagina. 

(^h)  Extraperitoneal  MethoJs. — 1 ,  Ligation  and  transfixion  ;  2, 
clamp  and  cautery  (Thomas)  ;  3,  serre-noeud  ;  4,  elastic  ligature. 

1.  Ligation  and  Transfixion. — Pedicle  is  ligated ;  two  skewers 
are  passed  through  it  and  brought  out  on  the  abdominal  surface. 
The  tumor  is  cut  oiF  beyond  the  ligature.  The  abdominal  wound  is 
closed  above  and  below  the  pedicle.  Antiseptic  dressing  changed 
frequently. 

2.  Clamp  ajid  Cautery  (Thomas). — Clamp  applied  and  screwed 
down.  Two  skewers  passed  through  the  pedicle  as  above.  Tumor 
cut  away.  Stump  thoroughly  cauterized.  Clamp  loosened,  but  left 
in  place.     Suture  of  wound  above  and  below.     Antiseptic  dressing. 

3.  Serre-Nrmid. — The  pedicle  is  transfixed  by  a  double  wire  liga- 
ture. Each  loop  is  twisted  tight  in  a  "  serre-noeud."  The  pedicle 
is  cauterized  and  secured  in  the  wound.  Sutures  and  antiseptic 
dressing, 

4.  Elastic  Ligature  (Hegar's). — Elastic  ligature,  5  mm.  in  diame- 
ter. Cauterization  of  the  stump  (a  strong  solution  of  chloride  of 
zinc  may  be  used).  Closure  of  peritoneum  around  the  stump 
separately.     Suture  and  antiseptic  dressing. 

Describe  the  local  treatment  of  large  subserous  fibroids  by  re- 
moval of  uterine  appendages. 

Tait's  Operation. — Removal  of  ovaries  and  tubes  may  be  per- 
formed to  check  the  growth  of  a  large  fibroid. 

Battey's  Operation. — Removal  of  the  ovaries  alone.  This  does 
not  have  the  desired  effect. 

FIBRO-CYSTIC  TUMOR   OF  THE   UTERUS. 
What  is  the  pathology? 

It  is  originally  a  fibroid  which  undergoes  softening,  and  in  which 
spaces  have  formed  and  become  filled  with  serous  fluid.  Sometimes 
these  spaces  have  an  endothelial  lining,  and  in  a  few  cases  the  con- 
tents become  gelatinous  and  fibro-myxoma  is  produced. 

What  are  the  symptoms? 

Rapid  growth ;  not  much  menstrual  disturbance ;  tumor  feels 
soft  in  some  places ;  hard  in  others,  and  moves  with  the  uterus. 


158  POLYPUS  OF  THE  UTERUS. 

What  is  the  differential  diagnosis? 

From  ovarian  cyst  it  is  made  ])y  the  presence  of  the  fibrous 
hardness  of  portions  of  the  tumor  and  by  its  relation  to  the  uterus. 

What  is  the  treatment  ? 
The  same  as  for  fibroids. 

UTERINE  POLYPUS. 

What  are  the  two  kinds? 

Fibrous  polypus  ;  mucous  polypus. 

Fihrous  Polypus. — This  is  a  pedunculated  submucous  fibroid. 

Mucous  Polypus. — This  is  a  pedunculated  tumor  attached  to  the 
mucous  membrane  (most  commonly  of  the  body)  of  the  uterus. 
The  tumors  are  usually  multiple,  and  vary  in  size  from  that  of  a 
pea  to  that  of  a  lima  bean.  They  are  soft  and  pulpy,  and  are  not 
round  or  pyriform,  but  flattened.     They  are  very  vascular. 

What  is  the  pathology  of  mucous  polypi  ? 

The  glands  are  the  same  as  in  the  normal  mucous  membrane  ; 
there  is  a  large  amount  of  connective  tissue,  and  immense  vascular 
supply.  Other  polypi  are  formed  from  retention  cysts,  occluded 
cervical  glands  which  have  become  pedunculated,  and  from  bits  of 
retained  placenta  or  from  placentae  succenturiatae  (placental  polypi). 

V/hat  are  the  symptoms  of  uterine  polypi  ? 

(1)  Hemorrhage ;  (2)  discharge ;  (3)  pain  ;  (4)  sterility ;  (5) 
symptoms  due  to  pressure  and  weight. 

(1)  Hemorrhage. — Tn  fibrous  polypus  hemorrhage  is  from  the 
mucous  membrane  of  the  body  of  the  uterus,  and,  as  a  rule,  is 
checked  when  the  polypus  is  pushed  into  the  vagina  by  uterine 
contraction.  Sometimes  the  capsule  ulcerates,  and  there  is  irregular 
hemorrhage  from  the  tumor  itself.  In  mucous  polypus  the  hemor- 
rhage is  from  the  tumor  itself,  and  one  no  larger  than  a  finger-tip 
may  cause  death.  In  polypi  formed  from  retention  cysts  there  is 
no  special  hemorrhage. 

In  placental  polypus  hemorrhage  is  from  the  tumor  itself,  and 
irregular  and  profuse. 

(2)  Discharge. — With  fibrous  polypus  there  is  little  discharge 
until  the  tumor  enters  the  cervix  or  vagina,  when  leucorrhoca  is 
excited.  With  the  different  varieties  of  mucous  polypi  leucorrhoea 
is  a  regular  symptom. 

(8)   Pain. — Dysmenorrha\a  is  always  present  with   fibrous   and 


NEOPLASMS   OF   THE   UTERUS. 


159 


placental  polypi  as  long  as  they  remain  in  the  uterine  cavity,  and 
especially  when  they  are  near  the  os  internum.  With  mucous 
polypi  and  those  from  retention  cysts  there  is  usually  no  pain 
unless  they  produce  obstructive  dysmenorrhcca. 

(4)  Sterility. — The  polypus  may  act  as  a  mechanical  obstacle  to 
the  entrance  of  spermatozoa  or  to  the  entrance  of  the  ovum  from 
the  tube. 

(5)  Pressure. — If  the  polypus  is  very  large,  there  may  be  vesical 
and  rectal  symptoms. 

In  rare  cases  there  are  present  the  symptoms  of  early  preg- 
nancy— morning  sickness,  enlargement  and  pigmentation  of  the 
breasts,  etc. 


What  are  the  physical  signs  of  uterine  polypi  ? 

Digital  Examination. — Fibrous  polypus  is  larger  than  a  walnut, 
firm,  and  its  attachment  is  high  up  ;  mucous  polypus  is  small, 
slippery,  and  its  pedicle  may  be  caught  in  the  cervix. 


Fro.  77. 


Fig.  78. 


Polypus. 


Complete  Inversion. 


Bimanual. — In  fibrous  polypus  the  uterus  is  enlarged  ;  in  mucous 
polypus  it  is  not. 


160  POLYPUS   OF   THE   UTERUS. 

Sound. — In  fibrous  polypus  the  uterine  cavity  is  lengthened ; 
in  mucous  polypus  the  uterine  cavity  is  not  lengthened. 

Speculum. — Fibrous  polypus,  pale  or  perhaps  ulcerated  ;  mucous 
polypus,  bright  red  and  either  smooth  or  like  a  raspberry, 

(When  the  os  is  closed,  to  determine  the  cause  of  the  hemor- 
rhage :  it  is  pretty  certainly  a  fibroid  polypus  if  the  uterus  is 
enlarged  and  its  cavity  lengthened.  But  if  the  uterus  is  not 
enlarged,  then  it  is  necessary,  to  complete  the  diagnosis,  to  dilate 
the  OS  and  introduce  the  finger  or  a  cervical  speculum.) 

Placental  polypi  are  diagnosed  by  microscopical  examination 
(club-shaped  tufts). 

What  is  the  differential  diagnosis  of  fibrous  polypus  from  complete 
inversion  of  the  uterus  ? 

(1)  Pass  the  finger  into  the  vagina  and  see  whether  the  mucous 
membrane  is  everywhere  reflected  on  to  the  tumor.  If  there  is 
an  opening  into  which  the  sound  may  be  passed,  the  tumor  is  a 
polypus. 

(2)  By  bimanual  examination  under  anaesthesia  the  fundus  of 
the  uterus  is  felt  in  the  normal  position  ;  similarly  recto-abdominal 
examination. 

(3)  Abdominal  palpation  is  sufficient  in  a  few  cases. 

What  is  the  prognosis  of  uterine  polypi  ? 

Good  if  removed. 

What  is  the  treatment  of  uterine  polypi  ? 

Removed. — Angcsthesia  should  generally  be  employed  ;  antiseptic 
precautions ;  the  cervix  is  thoroughly  dilated.  A  small  mucous 
polypus  may  be  seized  by  serrated  forceps  and  twisted  off",  or  it 
may  be  snipped  off"  with  scissors.  Pedunculated  cysts  are  simply 
snipped  off".  With  a  fibrous  polypus,  find  where  the  pedicle  is 
attached,  and  if  this  is  thin  seize  the  tumor  with  forceps  and  twist 
it  off".  If  the  pedicle  is  too  thick,  draw  the  tumor  down  gently 
and  cut  through  the  pedicle  with  scissors.  If  hemorrhage  is  likely 
to  be  excessive,  the  pedicle  m;iy  be  cut  through  with  the  6craseur 
or  the  galvano-cautery,  or  ligated  previous  to  cutting. 

Where  you  cannot  get  at  the  pedicle  the  tumor  may  be  torn 
away  piecemeal,  or  it  may  be  removed  by  Thomas's  method  :  seize 
the  tumor  at  its  lowest  part  and  excise  it  by  a  V-shaped  incision. 
Hemorrhage  may  require  the  use  of  the  cautery  and  packing  the 
uterine  canal  with  iodoform  gauze. 


NEOPLASMS   OF   THE   UTERUS.  161 

CARCINOMA    OF  THE  UTERUS. 

As  98  per  cent,  of  all  cases  are  of  the  cervix,  it  is  necessary  to 
describe  in  detail  only 

Oarcinoma  of  the  Oervix. 

What  is  its  etiology? 

Predisposing  Causes. — Race :  Irish  and  German,  Americans  less 
frequently,  and  negroes  rarely ;  sexual  excesses;  multiparae  (usually 
have  had  about  five  children).  Age  :  forty  to  fifty  most  common  ; 
thirty  to  sixty  are  the  usual  limits ;  heredity  is  not  marked.  Bad 
hygiene  :  it  is  much  more  common  in  the  poor. 

Exciting  Causes. — Laceration  of  the  cervix  ;  chronic  cervical 
catarrh  with  erosions. 

What  is  its  pathology? 

The  tumor  consists  of  connective  tissue  enclosing  alveoli  which 
are  filled  by  atypically  arranged  epithelial  cells.  When  the  con- 
nective tissue  is  greatly  in  excess,  the  tumor  is  said  to  be  scirrhous, 
fibrous,  or  "  hard  "  cancer.  When  the  cells  are  greatly  in  excess, 
the  tumor  is  a  medullary,  encephaloid,  acute,  or  '-  soft "  cancer. 

What  are  the  clinical  varieties? 

(1)  Squamous  epithelioma  or  cancroid  is  the  most  common  form. 
It  begins  on  the  vaginal  aspect  of  the  cervix  (where  the  epithelium 
is  squamous)  and  spreads  to  the  vaginal  wall,  but  not  to  the  cervical 
canal  until  quite  late.  The  cellular  elements  are  abundant,  and 
often  produce  large  "  cauliflower  masses."  It  may  involve  one  or 
both  lips  of  the  cervix.  Its  growth  is  rapid,  the  connective  tissue 
at  the  side  of  the  cervix  is  soon  infected,  and  finally  carcinomatous 
nodules  appear  in  the  substance  of  the  cervix. 

(2)  This  form  begins  as  small  cancerous  nodules  in  the  substance 
of  the  cervix.  These  ulcerate  their  way  through  to  the  vaginal 
aspect  or  to  the  cervical  canal.  The  growth  is  up  into  the  body 
of  the  uterus  and  into  the  pelvic  connective  tissue. 

(3)  This  form  occurs  rather  later  in  life.  It  begins  as  an  ulcera- 
tion of  the  cervical  endometrium,  and  extends  up  into  the  cavity 
of  the  uterus,  leaving  the  external  os  intact  for  a  long  time. 

(In  the  later  stage  all  these  forms  merge  into  each  other.) 

How  does  cancer  spread? 

1.  By  direct  extension  into  adjacent  tissues.  2.  By  infection 
through    the    lymphatic    system.      3.    By    infection    through    the 

ll-Gyn. 


162  CARCINOMA    OF   THE   UTERUS. 

blood-vessels  (rare,  but  very  rapid).  4.  Rarely  by  auto-inoculation 
from  contact  of  the  cancerous  cervix  with  the  vaginal  wall. 

1.  Direct  Extension. — To  the  vaginal  walls  ;  to  the  body  of  the 
uterus;  to  the  pelvic  connective  tissue;  to  the  peritoneum,  pre- 
ceded by  local  peritonitis  with  exudation  ;  to  the  ureters  (they  are 
almost  always  affected  in  advanced  cases,  and  finally  hydronephrosis 
is  produced)  ;  to  the  bladder  (the  muscular  coat  is  at  first  involved, 
later  the  mucous  membrane,  which  ulcerates  and  results  in  fistula)  ; 
to  the  rectum  rarely.  In  extreme  cases  the  entire  pelvic  contents 
are  glued  together  in  an  indistinguishable  mass. 

2  and  3.  Secondary  Infection. — To  the  inguinal,  retroperitoneal, 
and  lumbar  lymphatic  glands ;  ovary ;  liver ;  lungs ;  mammary 
glands,  rarely. 

What  are  the  symptcms  of  carcinoma  of  the  cervix  ? 

Hemorrhage,  discharge,  pain,  cachexia. 

Hemorrhage  begins  as  a  sudden  flooding  (not  as  profuse  men- 
struation) ;  it  comes  from  the  vascular  stroma  of  the  tumor.  It  is 
not  very  profuse,  and  is  rarely  fatal.  It  occurs  after  coitus  or 
after  some  muscular  effort. 

Discharge  is  not  abundant  until  ulceration  occurs.  It  can  only 
be  characterized  as  "  concentrated  rottenness."  In  the  early  stages 
it  is  light-yellow  and  watery.  Later  it  is  mixed  with  more  or  less 
blood,  and  may  be  a  bright-red  or  a  dirty  chocolate  color. 

Pain. — There  is  not  much  until  the  disease  extends  beyond  the 
cervix  ;  then  there  is  a  dull,  gnawing,  deep-seated  pain.  There 
may  be  shooting  pains.  Abdominal  pain  (late  stages  from  local 
peritonitis),  pain  in  the  breasts,  and  neuralgiae  also  occur. 

Cachexia. — There  are  anorexia,  indigestion,  emaciation,  urinary 
and  rectal  symptoms,  intense  vaginitis  and  vulvitis  from  contact 
with  the  discharge.  The  skin  is  of  a  characteristic  dull,  dingy 
color. 

What  are  the  physical  signs? 

1.  Digital  Examination. — Large  epithelioma  :  the  lip  is  inverted, 
and  a  friable  cauliflower  mass  is  felt  which  bleeds  readily  ;  cha- 
racteristic odor.  Small  epithelioma  :  there  is  slight  irregularity  of 
the  surface,  hemorrhage,  and  odor.  Nodular  carcinoma  :  the  finger 
recognizes  a  nodular  growth  in  one  lip  of  the  cervix.  Carcinoma 
originating  in  the  cervical  canal :  hemorrhage  and  offensive  dis- 
charge. 


NEOPLASMS  OF  THE  UTERUS.  163 

2.  Bimanual  and  Rectal  Examinations  should  be  made  to  deter- 
mine the  extent  of  involvement  of  neighboring  tissues. 

3.  Sj^eculum. — As  a  rule  unnecessary.  The  growth  is  pale 
yellow,  with  little  white  kernels,  and  has  a  sharply-defined  border. 

4.  Sound. — Unnecessary. 

What  is  the  differential  diagnosis? 

(1)  From  simple  hypertrophy  of  the  cervix  (in  this  the  cervix 
is  hard,  the  woman  young,  and  there  is  no  cachexia)  ;  (2)  from 
papillary  erosions  (these  may  develop  into  carcinoma,  and  the  micro- 
scope must  be  used  to  make  a  difi'erential  diagnosis)  ;  (3)  from 
sloughing  fibroid ;  (4)  from  sarcoma ;  (5)  from  diphtheritic  or 
syphilitic  ulceration. 

What  is  the  prognosis  ? 

Spontaneous  cure  probably  never  occurs.  Duration  of  life  is 
from  one  to  two  years.  The  most  rapid  cases  are  those  of  enceph- 
aloid  carcinoma. 

What  is  the  treatment? 

General. — Build  up  the  general  health,  forbid  coitus. 
Local. — (1)  Palliative.     (2)  Curative  (surgical  removal). 

(1)  Palliative  Treatment. — For  hemorrhage  injections  of  cool 
solutions  of  alum  or  tannin.  Sometimes  it  is  desirable  to  use  the 
sharp  spoon.     It  is  not  desirable  to  tampon  the  vagina. 

For  the  discharge^  if  not  offensive,  astringent  injections  of  alum 
or  tannin  ;  if  offensive,  add  permanganate  of  potash  or  some  other 
deodorizer. 

(2)  Curative  Treatment. — a,  Removal  by  caustics  ;  5,  removal 
by  curette  and  cautery ;  c,  amputation  of  cervix ;  c?,  removal  of 
uterus  entire. 

a.  Removal  by  Caustics :  Nitric  acid,  bromine  dissolved  in 
alcohol.  (Cylindrical  speculum,  caustic  applied  on  a  cotton  swab.) 
Not  a  valuable  or  desirable  method. 

h.  Removal  by  Curette  and  Cautery  :  Cut  away  the  mass  of  the 
disease  with  scissors,  and  then  with  Sims's  sharp  curette  scrape 
away  all  diseased  tissue.  The  vagina  is  protected  by  a  large 
tubular  speculum  while  the  entire  raw  surface  is  touched  with  the 
Paquelin  cautery.  A  tampon  of  iodoform  gauze  is  introduced, 
and  is  to  be  chan";ed  in  two  or  three  davs. 


164  CARCINOMA    OF   THE    UTERUS. 

c.  Amputation    of    the    Cervix :    The    different   methods    are — 

1,  circular  amputation  with  the  knife  ;  2,  circular  amputation  with 
the  ecraseur  or  galvano-cautery  (both  of  these  are  undesirable 
because  followed  by  cicatricial  stenosis)  ;  3,  Schroeder's  amputation. 

d.  Removal    of    uterus   entire :     1,    Abdominal    hysterectomy ; 

2,  vaginal  hysterectomy. 

Describe  abdominal  hysterectomy. 

Ether  and  careful  antisepsis.  The  patient  lies  upon  her  back  on 
a  flat  table  or  upon  Trendelenberg's  table  (by  which  the  pelvis  is 
raised  about  nine  inches  higher  than  the  shoulders,  thus  causing 
the  intestines  to  gravitate  toward  the  diaphragm,  and  giving  better 
access  to  the  pelvic  viscera).  An  incision  is  made  in  the  linea 
alba  between  the  umbilicus  and  the  pubes,  and  hemorrhage  is 
checked  before  the  peritoneal  cavity  is  entered.  The  broad  liga- 
ment on  each  side  is  tied  off  in  sections  and  divided  close  to  the 
uterus ;  care  is  taken  to  secure  the  uterine  artery  before  it  is 
divided.  The  fornices  of  the  vagina  are  cut  through  all  around 
and  the  uterus  removed.  The  ureters  must  be  avoided  during  the 
operation.  The  vagina  may  be  partially  closed  by  sutures  and 
packing  introduced.  The  abdominal  wound  may  be  sutured 
throughout  or  a  drainage-tube  (to  be  removed  in  twenty-four  to 
forty-eight  hours)  may  be  inserted  at  its  lower  angle.  An  anti- 
septic absorbent  dressing  is  applied. 

(This  has  been  almost  abandoned  as  an  operation  for  carcinoma 
of  the  uterus.) 

Describe  vaginal  hysterectomy. 

Ether  and  the  usual  antiseptic  precautions.  The  patient  is  in 
the  lithotomy  position,  and  the  vagina  opened  by  two  blunt  retrac- 
tors. The  cervix  is  seized  by  bullet  forceps  and  brought  down 
close  to  the  vulva.  The  posterior  fornix  of  the  vagina  is  cut 
through  with  scissors  or  a  scalpel.  Clamps  are  applied  at  each 
side  of  the  uterus,  and  each  broad  ligament  is  ligated  in  sections. 
The  fundus  of  the  uterus  is  seized  with  bullet  forceps  and  drawn 
down  through  the  incision  in  the  posterior  fornix,  and  the  organ  is 
then  excised.  (The  removal  may  be  done  equally  well  by  an 
incision  in  the  anterior  fornix.  The  fundus  of  the  vagina  may  be 
partially  closed  by  sutures  and  the  vagina  packed  with  iodoform 
gauze. 

(This  is  the  best  form  of  hysterectomy  for  carcinoma.  It  is  con- 
traindicated  where  the  uterus  is  not  freely  movable  and  in  cases  in 


INVERSION   OF  THE   UTERUS.  165 

which  extension  of  the  disease  to  the  pelvic  connective  tissue  has 
taken  place.) 

ADENOMA   OF   THE   UTERUS. 

Describe  adenoma  of  the  uterus. 

It  is  a  disease  consisting  in  a  hyperplasia  of  the  glandular  ele- 
ments of  the  endometrium,  forming  a  flattened  friable  mass  at  some 
part  of  the  uterine  cavity.  The  syiin'ptoms  produced  are  similar  to 
those  of  early  carcinoma,  hemorrhage  being  the  most  prominent. 
Treatment  is  dilatation,  thorough  removal  of  growth  with  a  spoon 
saw,  and  touching  the  raw  surface  with  fuming  nitric  acid.  The 
growth  has  a  marked  tendency  to  recur,  and  each  recurrence  should 
be  dealt  with  as  above.  The  ultimate  propiosis  of  cases  under 
treatment  is  good.  There  seems  to  be  evidence  that  neglected 
cases  may  become  malignant  from  development  of  sarcomatous  or 
carcinomatous  elements.     The  diagnosis  is  made  by  the  microscope. 

SARCOMA   OF   THE   UTERUS. 
Describe  sarcoma  of  the  uterus. 

The  tumor  consists  essentially  of  a  mass  of  connective-tissue 
cells ;  either  small  round  cells  or  spindle-shaped  cells,  not  occu- 
pying distinct  alveoli,  as  do  the  cells  in  carcinoma.  It  begins 
either  as  a  growth  having  the  gross  appearance  of  a  submucous 
fibroid  or  as  a  duffuse  infiltration  of  the  uterus.  The  early  symp- 
toms are  commonly  those  of  a  submucous  fibroid.  Later  symptoms 
are  like  those  of  carcinoma:  the  surface  ulcerates;  there  are  irreg- 
ular hemorrhage,  oiFensive  discharge,  and  the  escape  of  sloughy 
shreds  of  the  tumor.  The  diagnosis  is  made  by  the  microscojDe. 
The  jjrognosis  is  bad :  untreated  it  is  fatal  in  two  to  five  or  six 
years.  It  tends  to  recur  if  removed,  but  early  hysterectomy  ofi'ers 
a  better  chance  of  non-recurrence  than  in  the  case  of  carcinoma. 
Treatment  is  the  same  as  for  carcinoma.  Hysterectomy  is  usually 
indicated.  Ergot  has  been  employed,  as  for  a  submucous  fibroid,  to 
expel  the  tumor  by  uterine  contraction,  but  this  is  never  more  than 
palliative. 

INVERSION  OP  THE  UTERUS. 

What  are  its  definition  and  occurrence? 

It  is  a  condition  in  which  the  uterus  is  either  partially  or  com- 
pletely turned  inside  out. 


166 


INVERSION   OF   THE   UTERUS. 


Fig.  79. 


In  partial  inversion  some  part  of  the  uterine  wall  (commonly  the 
region  of"  one  of  the  tubes)  is  inverted  into 
the  uterine  cavity ;  this  is  marked  on  the 
external  surface  of  the  uterus  by  a  ring 
encircling  a  deep  depression,  and  on  the 
internal  surface  by  a  rounded  mass  exactly 
similar  to  a  submucous  fibroid. 

In  comj)lete  inversion  the  fundus  is  forced 
through  the  external  os,  and  the  uterus  lies 
in  the  vagina  or  protrudes  from  the  vulva  as 
a  pyriform  mass  covered  by  endometrium. 

There  is  good  authority  for  the  statement 
that  it  can  occur  in  the  nulliparous  uterus, 
but  this  is  very  rare  indeed.  It  occurs  com- 
monly in  uteri  relaxed  by  recent  parturition, 
and  is   commonly  acute — i.  e.  of  sudden   production — although  a 


Coiuplete  Inversion. 


Fig.  80. 


Fig.  81. 


Polypus. 


Partial  Inversion. 


chronic  form  is  also  described  in  which  the  inversion  takes  place 
gradually. 


INVERSION   OF   THE   UTERUS. 


167 


What  is  its  etiology? 

Predisposing  Causes — Parturition  ;  distension  of  the  uterus  by 
retained  fluids  ;  distension  of  the  uterus  by  tumors. 

Exciting  Causes. — Traction  on  the  placenta  ;  traction  by  polypi 
or  tumors  ;  sudden  delivery  of  child  by  traction  ;  muscular  efforts 
when  relaxation  exists. 

What  are  its  symptoms  ? 

On  its  first  occurrence,  shortly  after  labor,  there  are  pain,  faint- 
ness,  hemorrhage,  and  the  presence  of  a  large  flabby  mass  (perhaps 
with  the' placenta  attached  to  it)  protruding  from  the  vulva. 

Cases  which  have  existed  for  months  or  years  present  the  follow- 
ing :  occasional  or  constant  hemorrhage  ;  dragging  pains  in  back 
and  loins  ;  difiiculty  in  locomotion  ;  difficulty  in  micturition  and 
defecation ;  anaemia,  etc. 

What  is  the  differential  diagnosis? 

It  is  based  upon  the  physical  signs : 


Polypus. 

Probe  will  usually  pass  beyond 
it  into  the  uterus. 

Bimanual  examination  will  re- 
veal the  body  of  the  uterus 
in  situ. 

Rectal  examination  gives  the 
same  positive  evidence. 

Recto-vesical,  the  same. 

Acupuncture  is  painless. 

Submucous  Fibroid. 

Probe  shows  uterine  cavity 
lengthened. 

Bimanual  examination  and  Si- 
mon's method  (with  hand  in 
rectum)  show  the  body  of  the 
uterus  to  have  its  normal  ro- 
tundity. 

Gradual  development. 

Independent  of  parturition. 

Acupuncture  painless. 


Complete  Inversion. 
Probe  is  arrested. 

Bimanual  examination  reveals  a 
ring  where  the  uterus  should 
be. 

Rectal  examination  is  negative. 

Recto-vesical,  negative. 
Acupuncture  is  painful. 

Partial  Inversion. 
Probe  shows  cavity  diminished. 

Bimanual  and  Simon's  methods 
both  show  a  small  circular  de- 
pression on  the  surface  of  the 
uterus. 

Sudden  development. 
Usually  follows  parturition. 
Acupuncture  painful. 


168 


INVERSION    OF   THE   UTERUS. 


What  is  the  prognosis  ? 

Inversion  occurring  after  labor  is  a  grave  accident,  and  may  be 
followed  by  death  from   hemorrhage.     If  untreated,  it  will  com- 


FiG.  82. 


Fig.  83. 


Fibrous  Polypus. 


Partial  Inversion. 


monly  persist  permanently,  though  there  are  cases  on  record  of 
spontaneous  recovery  even  years  afterward.  The  mechanism  by 
which  this  takes  place  is  obscure.  The  dangers  in  old  cases  are 
connected  chiefly  with  improper  diagnosis  and  treatment.  Thus, 
it  may  be  mistaken  for  a  fibrous  polypus,  and  an  operation  for  this 
supposed  trouble  may  result  in  amputation  of  the  uterus  ;  or  in 
efforts  at  replacement  rupture  of  the  vagina  may  be  produced. 
The  lesion  in  itself  presents  in  general  the  dangers  of  the  worst 
form  of  fibrous  polypus. 

What  is  the  treatment? 

Palliative  :   Control  of  hemorrhage  by  the  use  of  astringent  solu- 
tions (alum,  tannin,  persulphate  of  iron,  or  acetate  of  lead). 

Curative  :   Rejiosition  ;  as  a  last  resort,  amputation. 


Gradual 
reduction. 


Methods  hy  Reposition. 

r  Elastic  pressure  by  vaginal  stems  and  cup  or  bulb. 
\  Elastic  pressure  by  vaginal  water-bag  combined  with 
(_  occasional  taxis. 


INVERSION   OF   THE   UTERUS.  169 

p     ,     ,       r  Elastic  pressure  by  vaginal  water-bags  alone. 

T  .  ^  A  stream  of  cold  water  directed  tbroueli  a  tubular 
reduction.   ;  i         +    •  j 

(_  speculum  twice  a  day. 

ViradeFs    method. 
Emmet's  " 

Farrier's  " 

Rapid   re-    ■  Noeggerath's  " 
duction.     '  Courty's  " 

Thomas's         " 
White's  " 

^Tate's 

All  these  rapid  methods  of  replacement  require  anaesthesia,  and 
should  not  be  resorted  to  (under  ordinary  circumstances)  until  the 
milder  methods  of  gradual  replacement  have  been  fairly  tried  and 
have  failed.  They  all  consist  in  pressure  upon  the  fundus  and 
counter-pressure  upon  the  cervical  ring.  For  example,  Courty's 
method  consists  in  passing  the  index  and  middle  fingers  up  the 
rectum  and  dipping  them  into  the  cervial  ring  while  pressure  is 
made  upon  the  fundus  by  the  thumb  and  by  the  other  hand.  This 
method  is  especially  useful  in  effecting  the  re-inversion  of  the  cervix. 
Noeggerath's  method  consists  in  placing  the  index  finger  on  one 
horn,  the  thumb  on  the  other,  and  so  compressing  as  to  invert  one 
or  both  cornua.  It  is  highly  effective,  but  only  after  re-inversion 
of  the  cervix  by  Courty's  or  some  similar  method.  Thomas's 
method  is  the  only  one  in  which  the  abdomen  is  opened.  Through 
a  suprapubic  incision  the  cervical  ring  is  dilated  by  an  instrument 
like  a  glove-stretcher  while  pressure  is  made  upon  the  fundus  from 
below. 

Amputation  of  the  Uterus. 

This  operation  is  resorted  to  in  cases  in  which  all  attempts  at 
reduction  have  failed,  and  in  which  the  symptoms  (chief  of  which 
is  hemorrhage)  are  sufficient  to  justify  so  grave  a  step. 

Its  dangers  are — (1)  If  hernia  of  the  abdominal  or  pelvic  viscera 
have  taken  place  into  the  inverted  sac ;  (2)  it  frequently  pro- 
duces emansio-mensium  with  its  sequelae ;  (3)  it  produces  sterility ; 
(4)  the  mortality  is  very  great :  33  per  cent,  of  all  recorded  cases 
were  fatal. 

Methods. 

1.  Elastic  ligature,  retightened  on  the  second  day,  the  uterus 


170  DISEASES   OF   THE   OVAKIES. 

coming    away    about   the    fourteenth    day.      (This    is    the    safest 
method.) 

2.  Knife  or  ^craseur. 

3.  Knife  or  ecraseur  preceded  by  ligature. 

DISEASES  OF  THE  OVARIES. 

ANATOMY  OF  THE  FALLOPIAN  TUBES  AND  OVARIES. 

Describe  the  Fallopian  tubes. 

The  Fallopian  tubes  are  two  tubes,  from  4  to  6  inches  in  length, 
which  spring  from  the  upper  angles  of  the  uterus  and  run  tortu- 
ously outward  in  the  free  margin  of  the  broad  ligaments.  Each  is 
divided  into  three  portions — the  isthmus,  ampulla,  and  fimbriated 
extremity.  The  isthmus  is  the  smaller  straight  portion.  It  is 
1  inch  long,  and  will  just  admit  a  bristle  into  its  lumen.  The 
ampulla  is  the  larger  external  portion,  which  extends  first  outward, 
then  forward  and  downward.  It  is  6  to  8  mm.  in  diameter.  The 
fimbriated  extremity,  or  '•  infundibulum,"  is  the  funnel-shaped  ex- 
pansion, surrounded  by  numerous  little  fleshy  processes  or  fimbriae. 
There  are  four  to  five  large  primary  and  ten  to  twelve  small 
secondary  fimbriae.  One  of  the  long  primary  fimbria)  on  the  inner 
side  runs  to  the  ovary,  and  is  called  the  "  fimbria  ovarica." 

The  tubes  are  composed  of  three  coats — serous,  muscular,  and 
mucous  membrane.  The  muscular  coat  is  arranged  in  two  layers, 
an  external  longitudinal  and  an  internal  circular  set  of  fibres.  The 
mucous  membrane  is  thrown  into  numerous  folds,  and  is  covered 
by  a  layer  of  ciliated  columnar  epithelium,  which  becomes  con- 
tinuous with  the  peritoneal  epithelium  at  the  free  end  of  the  tube. 
The  cilia  move  toward  the  uterus.  There  is  no  submucous  layer, 
and  the  mucous  membrane  contains  no  glands. 

The  arterial  supply  is  derived  from  the  ovarian  artery  and  the 
ovarian  plexus.  The  veins  enter  the  pampiniform  plexus.  The 
nerve-supply  is  derived  from  the  inferior  hypogastric  plexuses. 
The  lymphatics  unite  with  those  of  the  ovary. 

Describe  the  parovarium. 

The  parovarium,  or  organ  of  Rosenmiiller  (analogue  of  the  epi- 
didymis in  the  male),  is  a  rudimentary  structure,  the  remains  of 
the  Wolffian  body.  It  consists  of  a  triangular  group  of  small 
tubules  situated  between  the  folds  of  the  mesosaplinx.  These 
tubules    converge   to   the    ovary   and    are    lined   with   epithelium. 


ANATOMY   OF   THE   OVARIES.  171 

They  are  united  above  by  one  transverse  tubule,  which  has  its 
blind  extremity  near  the  fimbriated  end  of  the  Fallopian  tube. 
In  the  other  direction  it  can  be  traced  as  a  cord  nearly  to  the 
uterus,  and  is  known  as  the  persistent  duct  of  Gartner,  Cystic 
dilatations  are  sometimes  seen  in  these  ducts,  and  may  appear 
in  the  anterior  vaginal  wall.  The  most  common  form  of  these 
cysts  is  known  as  the  "  hydatids  of  Morgagni,"  which  spring  from 
the  mesosalpinx  to  the  inner  side  of  the  fimbria  ovarica.  The  paro- 
varium is  thus  of  considerable  importance,  from  its  tendency  to 
form  cysts  of  the  broad  ligaments. 

Describe  the  ovaries. 

The  ovaries  are  two  small  oval  bodies  situated  one  on  either 
side  of  the  uterus,  and  about  1  inch  from  it,  projecting  in  the 
posterior  layer  of  the  broad  ligaments.  Each  ovary  is  about  the 
size  of  an  almond,  1-2  inches  long,  |-1  inch  in  width,  and  i-J  inch 
in  thickness.  Their  weight  is  from  60  to  135  grains.  They  present 
for  examination  an  anterior  and  posterior  border,  an  upper  and 
lower  surface,  and  an  outer  and  inner  extremity.  The  anterior 
border,  called  the  hilus,  is  flattened  and  attached  to  the  anterior 
layer  of  the  broad  ligaments.  The  blood-vessels  and  nerves  enter 
here.  The  posterior  border  is  rounded  and  free.  The  upper  sur- 
face is  more  convex  than  the  lower.  The  outer  extremity  is  bulb- 
ous ;  the  inner  is  more  attenuated,  and  is  connected  to  the  uterus 
by  the  ovarian  ligament. 

The  ovarian  ligaments  are  fibro-muscular  bands  of  the  broad  liga- 
ment, one  inch  long,  which  spring  from  the  uterus  just  below  the 
Fallopian  tubes.  The  other  ovarian  ligaments  are  the  infundibulo- 
pelvic,  which  is  the  outer  free  margin  of  the  broad  ligament,  not 
containing  the  Fallopian  tube,  and  the  fimbria  ovarica,  which  con- 
nects the  ovary  to  the  infundibulum.  The  external  covering  of  the 
ovary  is  composed  of  a  layer  of  short  columnar  epithelium  called 
"  germinal  epithelium,"  because  from  their  cells  the  primitive  ova 
are  supposed  to  spring.  Its  union  with  the  squamous  peritoneal 
epithelium  at  the  hilus  is  marked  by  a  -  white  line."  Ingrowths 
of  this  germinal  epithelium  in  the  stroma  are  called  the  "  tubes  of 
Pfliiger."  The  epithelial  layer  rests  directly  upon  a  thin  layer  of 
dense  fibrous  tissue  called  the  "  tunica  albuginea."  The  paren- 
chyma of  the  ovary  is  composed  of  a  cortical  and  medullary  por- 
tion. The  cortex  or  superficial  portion  is  less  vascular  than  the 
medullary.     It  consists  of  a  network  of  connective  tissue,  elastic 


172  DISEASES   OF   THE   OVARIES. 

and  muscular  fibres,  imbedded  in  which  are  numbers  of  Graafian 
vesicles,  blood-vessels,  nerves,  and  lymphatics.  The  medullary 
layer  is  composed  of  the  same  elements  as  the  cortex,  but  is  less 
dense  and  more  vascular. 

The  Graafian  vesicles,  or  ovisacs,  are  formed  from  the  tubes  of 
Pfliiger  (ingrowths  of  the  germinal  epithelium).  They  vary^  in  size 
when  mature  from  y^^  to  ^^^  of  an  inch  in  diameter.  From  40,000 
to  70,000  Graafian  follicles  are  contained  in  the  ovary  at  birth. 
Each  follicle  consists  of  an  external  covering,  the  tunica  fibrosa, 
which  contains  the  network  of  blood-vessels,  and  the  memhrana  pro- 
pria, on  which  rests  a  layer  of  nucleated  columnar  epithelium,  the 
memhrana  granulosa.  Inside  this  the  vesicle  is  filled  with  a  clear 
fluid,  the  '-'  liquor  folUculir  At  one  portion  the  membrana  granu- 
losa surrounds  the  ovum  and  forms  the  discus  proligerus.  The 
ovum  itself,  j^^  inch  in  diameter,  is  composed  of  an  external  envel- 
ope, the  vitelline  membrane  or  zona  pellncida,  within  which  is  the 
vitellus  or  i/olk.  At  one  side  of  this  is  the  germinal  vesicle,  which 
contains  the  germinal  spot. 

The  arterial  supply  of  the  ovary  is  derived  from  the  ovarian 
artery,  which  arises  directly  from  the  aorta.  From  its  origin  it 
bends  inward  and  runs  tortuously  between  the  folds  of  the  broad 
ligament  to  the  upper  angle  of  the  uterus.  Here  it  divides  into 
two  branches,  one  going  to  the  fundus  and  anastomosing  with  its 
fellow,  the  other  descending  to  unite  with  the  uterine.  It  gives 
branches  to  the  infundibulum,  and  numerous  tortuous  branches 
to  the  ovary,  which  enter  the  hilus  and  form  plexuses  about  the 
Graafian  follicles.  The  veins  leave  the  hilus  and  unite  with  the 
uterine  plexus  and  veins  from  the  tubes  to  form  the  pampiniform, 
plexus.  They  terminate  in  the  ovarian  veins,  the  right  emptying 
into  the  vena  cava  direct,  and  the  left  into  the  renal  vein. 

The  nerves  are  derived  from  the  ovarian  plexus  and  accompany 
the  arteries.     The  lymphatics  enter  the  lumbar  glands. 

MALFORMATIONS   OF   THE   OVARY. 
Describe  malformations  of  the  ovary. 

Absence  of  the  ovaries  is  very  rare  :  it  is  associated  v>^ith  rudi- 
mentary development  of  the  rest  of  the  genital  system.  The  patient 
may  retain  throughout  life  the  development,  physical  and  mental, 
of  a  child,  or  in  rare  instances  may  present  the  stature,  beard,  and 
mental  characteristics  of  the  male  sex.     In  any  case  menstruation 


ATROPHY    AND    DISPLACEMENTS    OF    THE    OVARIES.      173 

never  occurs,  and  the  woman  is  sterile  and  sexual  feeling  is  absent. 
Diagnosis  is  made  from  the  symptoms  and  from  the  mal-develop- 
ment  of  the  other  sexual  organs.  Treatrtient  is  without  benefit, 
and  may  do  harm  in  breaking  down  the  health  by  persistent  efforts 
to  excite  the  functions  of  the  ovaries  (under  a  mistaken  diagnosis). 

Imperfect  and  Irregular  Development  of  the  Ovaries. — A  woman 
with  imperfectly  developed  ovaries  may  present  similar  general 
symptoms  to  one  in  whom  the  ovaries  are  absent.  The  local 
symptoms  are  irregular  or  scanty  menstruation,  often  sterility. 
Treatment  is  directed  toward  stimulation  of  the  generative  func- 
tions, as  by  general  tonics,  uterine  irritation  (tents  or  stems), 
electricity,  marriage. 

The  cases  of  irregular  development  of  the  ovaries,  including 
supernumerary  ovary,  would  present  no  special  interest,  except  to 
the  pathologist,  but  for  the  fact  that  they  may  account  for  some 
cases  in  which  removal  of  the  ovaries  is  followed  by  menstruation 
or  even  conception. 

ATROPHY  OF    THE   OVABIES. 

Describe  atrophy  of  the  ovaries. 

The  premature  development  of  the  senile  condition  in  the  ovaries 
is  accompanied  by  similar  changes  in  the  rest  of  the  generative 
system,  and  by  the  cessation  of  menstruation  and  the  other  sexual 
functions.  The  ovary  may  weigh  15  grains,  the  normal  weight 
being  100  grains. 

What  are  the  causes? 

Ovaritis,  acute  or  chronic  ;  pelvic  peritonitis ;  the  exanthemata. 

What  is  the  treatment? 

Stimulation  of  the  sexual  functions,  as  for  imperfect  develop- 
ment of  the  ovaries. 

What  is  the  prognosis? 

The  condition  is  not  dangerous  to  life,  but  if  all  signs  of  men- 
struation are  absent  the  prospect  of  cure  is  poor. 

DISPLACEMENTS  OF   THE   OVARY. 

Name  the  two  displacements  of  the  ovary. 
Prolapse  and  hernia. 


174  DISEASES   OF   THE   OVARIES. 

Describe  prolapse  of  the  ovary. 

One  or  both  of  the  ovaries  may  be  displaced  into  Douglas's 
pouch. 

What  are  the  causes? 

Retroversion  or  retroflexion  of  the  uterus ;  enlargement  of  the 
ovaries  from  congestion  ;  chronic  ovaritis,  or  diffuse  cystic  degene- 
ration. 

What  are  the  symptoms? 

Dyspareunia ;  pain  on  defecation  when  the  bladder  is  distended  ; 
sacral  pain,  and  pain  in  the  ischio-rectal  fossa  and  hip  extending 
down  the  thigh  on  the  corresponding  side. 

What  are  the  physical  signs? 

On  digital  examination  one  or  two  bodies  the  size  and  shape  of 
the  ovaries  can  be  readily  felt  in  Douglas's  pouch,  movable  inde- 
pendently of  the  uterus,  and  producing  on  pressure  a  sickening 
sensation  analogous  to  that  from  pressure  on  the  testicle. 

What  is  the  treatment? 

(1)  Reposition  by  the  knee-chest  position  (maintained  fifteen 
minutes  at  a  time  twice  daily).  (2)  Use  of  a  pessary  (the  best  for 
most  cases  is  a  soft-rubber  ring).  (3)  Palliative  treatment  (for- 
bid coitus  ;  prevent  the  formation  of  hard  scybala  in  the  rectum  ; 
remove  pressure  from  above  by  an  abdominal  belt ;  if  conception 
is  probable,  encourage  it  in  the  belief  that  the  nine  months'  rest 
from  functional  activity  may  restore  the  ovaries  and  their  attach- 
ments to  their  normal  condition).  (4)  Removal  of  the  affected 
ovary  or  ovaries  by  abdominal  or  vaginal  section,  if  adhesions 
have  rendered  other  treatment  unsuccessful  and  the  system  calls 
for  such  grave  measures. 

Describe  hernia  of  the  ovary. 

In  congenital  hernia  of  the  ovary  the  ovary  on  one  or  both  sides 
lies  in  the  labium  majus,  having  come  down  through  the  unobliter- 
ated  canal  of  Nuck.  The  swelling  may  be  mistaken  for  the  testis, 
as  in  some  cases  of  supposed  hermaphroditism  ;  when  congenital  it 
is  often  irreducible,  and  may  give  pain  on  locomotion  and  coitus. 
The  treatment  consists  in  the  application  of  a  suitable  truss  where 
the  hernia  is  reducible.  For  irreducible  hernia  a  concave  protective 
truss-pad  may  be  worn,  or  if  symptoms  are  sufficiently  severe  the 
ovary  may  be  removed  by  a  labial  incision. 


OVARIAN   APOPLEXY.  175 

In  acquired  hernia  of  tlie  ovary,  the  ovary  may  form  part  of  the 
contents  of  an  inguinal,  femoral,  sciatic,  or  ventral  hernia.  The 
symptoma  and  treatment  are  the  same  as  for  the  congenital  variety. 

OVARIAN   APOPLEXY. 

Describe  ovarian  apoplexy. 

The  lesion  is  a  rapid  effusion  of  blood  into  the  substance  of  the 
ovary  from  rupture  of  one  or  more  of  its  larger  blood-vessels.  (It 
is  not  to  be  confounded  with  the  physiological  extravasation  from 
which  the  corpus  luteum  is  produced.)  It  may  be  small^  or  it  may 
distend  the  ovary  to  the  size  of  an  orange,  or  it  may  rupture.  Its 
cause  is  either  some  mechanical  shock  or  a  pathological  exaggeration 
of  the  hemorrhage  during  ovulation.  Symptoms  are :  sudden  and 
violent  pain  over  one  ovary,  combined  with  some  of  the  symptoms 
of  internal  hemorrhage.  Diagnosis  is  difficult.  With  the  symp- 
toms mentioned  above  and  the  presence  of  a  cystic  tumor  felt  on 
digital  examination,  the  contents  of  which  on  aspiration  through 
the  vaginal  wall  were  found  to  be  dark-bloody  fluid,  this  diagnosis 
would  probably  be  correct.  Prognosis  is  grave.  The  blood-clot 
may  become  absorbed  or  organized,  but  if  the  ovarian  tissues  have 
been  largely  disorganized,  even  this  favorable  termination  may  be 
followed  by  symptoms  (pain  chiefly)  calling  for  radical  treatment. 
In  unfavorable  cases  the  hematoma  may  rupture  into  the  peritoneal 
cavity  (forming  a  pelvic  haematocele  shut  off  by  peritonitic  adhe- 
sions from  the  general  cavity),  or  between  the  layers  of  the  broad 
ligament,  where  a  mass  may  be  formed  giving  rise  to  pressure 
symptoms. 

Treatment. — Early :  check  hemorrhage  by  rest  in  bed  and  ice- 
bags,  and  control  pain  by  morphine.  Later,  if  peritonitis  develop, 
this  is  to  be  treated  in  the  usual  way.  When  the  acute  symp- 
toms are  over,  treatment  is  directed  toward  the  reabsorption  of  the 
effusion,  similar  to  that  for  inflammatory  pelvic  exudations.  If 
symptoms  are  sufficiently  severe,  removal  of  the  affected  ovary  is 
indicated. 

INFLAMMATIONS   OF   THE  OVARY. 
What  are  the  two  degrees  of  ovarian  inflammation  ? 
Acute  ovaritis  ;  chronic  ovaritis. 

Describe  acute  ovaritis. 

This  may  be  puerperal  or  non-puerperal.     In  the  former  case  the 


176  DISEASES   OF   THE   OVARIES. 

process  is  more  severe,  and  termination  in  suppuration  is  more  com- 
mon, than  in  the  non-puerperal  form,  where  resolution  is  the  rule. 
The  causes  are  acute  endometritis,  acute  salpingitis,  pelvic  perito- 
nitis, gonorrhoea,  disturbance  of  menstruation.  The  symptoms  are 
those  of  pelvic  inflammation — fever,  pain,  and  sensitiveness.  If 
resolution  takes  place,  the  symptoms  subside  after  four  or  five  da3's, 
but  if  suppuration  occurs,  there  are  rigors  and  irregular  rise  of 
temperature,  and  finally  symptoms  referable  to  the  rupture  of  an 
abscess  into  the  peritoneum,  rectum,  bladder,  or  vagina.  The  jyrog- 
nosis  in  puerperal  cases  is  grave ;  in  non-puerperal  cases  it  is  fairly 
good.  In  all  cases  the  ovary  is  left  somewhat  damaged,  and  in 
gonorrhoeal  cases  of  double  ovaritis,  sterility  is  sure  to  follow. 
Treatment  consists  in  antiphlogistics  and  opiates,  and,  if  suppura- 
tion occurs,  extirpation  of  the  ovary  by  laparotomy  or  drainage  of 
the  abscess-cavity  by  abdominal,  rectal,  or  vaginal  incisions. 

Describe  chronic  ovaritis. 

Pathology. — In  the  early  stages  the  condition  is  that  of  chronic 
congestion,  followed  by  infiltration  with  sero-sanguinolent  fluid  and 
an  increase  in  bulk.  In  the  later  stages  the  capsule  thickens,  the 
follicles  enlarge,  and  a  general  hypertrophy  takes  place.  It  starts 
commonly  as  a  subacute  or  chronic  affection,  rarely  as  an  acute 
ovaritis. 

Causes. — They  are  those  that  produce  prolonged  congestion  of 
the  generative  organs  :  laceration  of  the  cervix  or  perineum  ;  sub- 
involution ;  dysmenorrhoea  ;  uterine  tumors  ;  displacements  and 
flexions  ;  sterility  ;  efforts  to  prevent  conception  ;  intercourse  with 
impotent  men  ;  masturbation  ;  emotional  causes  (long  engagements, 
disappointment  in  love,  reading  corrupt  literature,  etc.). 

Hympto^ns. — Dysmenorrhoea ;  fixed  ovarian  pain  ;  tendency  to 
hysteria ;  rarely  pain  on  locomotion  ;  sometimes  dyspareunia  ;  pain 
and  exhaustion  after  defecation  ;  pain  in  rectum,  hips,  and  down 
thighs  ;  irregular  menstruation  ;  sterility  if  both  ovaries  are 
affected. 

Treatment. — (1)  Removal  of  causes  of  congestion  (thus,  repair 
of  laceration  of  cervix  or  perineum,  correction  of  displacement  or 
flexion  of  the  uterus,  regulation  of  the  bowels  and  of  sexual  rela- 
tions, etc.).  (2)  Reduce  pelvic  engorgement  directly  by  scarifying 
the  cervix  ;  prolonged  hot  vaginal  douches  ;  painting  the  vaginal 
fornix  with  tincture  of  iodine  if  tenderness  and  induration  appear 
in    either    broad    ligament;    rest   during    menstruation;    bromides. 


NEOPLASMS  OF  THE  OVARY.  177 

general  tonics,  and  sometimes  a  sea-voyage.  (3)  The  very  best 
treatment  is  Weir  Mitchell's  rest-cure.  (4)  Some  cases  resist  all 
treatment,  and  are  sufficiently  serious  to  justify  the  removal  of 
the  affected  ovary  or  ovaries. 

ABSCESS  OF  THE  OVARY. 
Describe  abscess  of  the  ovary. 

It  is  a  collection  of  pus  in  the  substance  of  the  ovary.  It  occurs 
almost  exclusively  in  connection  with  gonorrhoeal  or  tubercular 
inflammation  of  the  genital  tract.  It  gives  no  very  characteristic 
symptoms  in  addition  to  those  of  the  disease  it  complicates,  but 
may  commonly  be  diagnosed  by  finding  on  physical  examination 
the  ovary  distended  with  fluid,  while  the  presence  of  irregular 
temperature  and  rigors  indicates  its  purulent  character. 

Treatment  is  commonly  removal  of  the  ovary  by  laparotomy  or 
drainage  of  the  abscess-cavity  by  the  incision  which  seems  most 
appropriate  for  the  individual  case. 

NEOPLASMS  OF  THE  OVARY. 

Enumerate  the  neoplasms  of  the  ovary. 

I.  Solid  Tumors. 

r\      •  -^  C  accompanied  by  rap- 

Carcmoma,   )        ,.  ,      o  •  ^  )       -n         i       i     • 

q  '   V  malignant ;  lairly  common ;  <      idly      developing 

'       ^  (_     ascites. 

Papilloma,    )  doubtful;  rare;)         ,.  ,.        .  i  . 
Fibroma,      |  benign.        "       | "°  'J'^t'iS'iislimg  symptoms, 

IT.    Cystic  Tumors. 

Cysto-carcinoma,    )         ,. 

ry     ,  '    ^    malignant. 

Cysto-sarcoma,       j  ^ 

Cysto-fibroma,  ") 

Dermoid  cyst,  y  benign. 

Ovarian  cyst  (mono-  or  polycystic),  j 

DERMOID   CYST  OF  THE   OVARY. 

Describe  dermoid  cyst. 

In  various  parts  of  the  body  (the  orbit,  floor  of  the  mouth,  brain, 
eye,  anterior  mediastinum,  lung,  mesentery,  testicle,  and  ovary) 
tumors  may  occur,  containing  fatty  matter,  teeth,  hair,  cartilage,  and 

12— Gjn. 


178  DISEASES   OF   THE   OVARIES. 

bone.  Their  origin  must  be  in  some  foetal  inclusion  of  epiblast  and 
irregular  subsequent  development  of  the  same.  Those  occurring 
in  the  ovary  vary  in  size  from  that  of  a  hen's  egg  to  that  of  a 
human  head.  In  themselves  they  give  no  special  symptoms,  but 
always  present  the  risk  of  rupture  into  the  peritoneal  cavity  or 
of  suppuration.  They  should  probably  always  be  removed  by 
ovariotomy. 

OVABIAN  CYSTS. 

What  is  the  pathology  of  ovarian  cysts  ? 

The  development  of  cysts  within  the  ovary  without  the  coinci- 
dent development  of  solid  elements,  as  fibroma  or  carcinoma.  Most 
of  the  cysts  are  developed  from  the  Graafian  follicles  by  a  sort  of 
colloid  degeneration,  but  it  is  claimed  that  some  may  originate  in 
cystic  degeneration  of  the  ovarian  stroma.  The  cyst  may  be  mono- 
cystic  or  polycystic ;  and  in  the  latter  case  the  separate  collec- 
tions of  fluid  may  be  enclosed  by  thick  or  very  thin  walls.  The 
fluid  may  be  very  thin  and  clear,  or  may  be  viscid,  or  even 
almost  gelatinous ;  its  color  varies  from  a  pale  yellow  to  that  of 
weak  coff"ee.  Under  the  microscope  certain  bodies,  "  Drysdale's 
cells,"  are  seen  which  are  not  distinctly  altered  by  acetic  acid 
(which  does  markedly  change  the  appearance  of  leucocytes,  etc.)  ; 
they  are  characteristic  of  fluid  from  an  ovarian  cyst,  but  not 
absolutely  diagnostic.  The  pedicle  consists  of  the  broad  ligament, 
the  Fallopian  tube,  the  round  ligament,  the  ovarian  vessels,  etc. 
In  one  variety,  "  intraligamentous  cysts,"  there  is  no  true  pedicle, 
and  the  tumor  can  only  be  removed  by  difficult  dissection  ;  often 
it  can  only  be  drained. 

What  are  the  causes? 

Predisposmg. — Age  twenty  to  fifty  most  common  ;  childbearing ; 
chlorosis ;  scrofulous  diathesis ;  menstrual  disorders ;  deprivation 
and  bad  hygiene. 

Exciting. — Uncertain  ;  ovaritis,  acute  or  chronic ;  the  various 
causes  of  pelvic  congestion.  In  the  great  majority  of  cases  the 
woman  has  been  apparently  perfectly  well  until  the  tumor  has 
developed  and  reached  a  size  at  which  it  has  given  symptoms. 

What  are  the  symptoms? 

They  are  not  pathognomonic,  and  are  largely  due  to  the  pressure 
of  the  tumor  upon  the  pelvic  and  abdominal  structures  as  it  gets 


NEOPLASMS  OF  THE  OVARY.  179 

larger  and  larger.  (The  tumor  reaches  a  size  from  that  of  a  human 
head  to  a  mass  weighing  sometimes  over  a  hundred  pounds.)  The 
abdomen  is  distended ;  there  are  marked  emaciation  of  the  lower 
extremities,  emaciation  of  the  face,  and  a  peculiar  expression, 
"  facies  ovariana." 

What  are  the  complications  ? 

Pregnancy ;  fibroids  of  the  uterus ;  carcinoma  of  the  uterus ; 
renal  disease  ;  disease  of  the  liver,  heart,  or  lungs  ;  compression  of 

the  ureters  ;  elevation  of  the  bladder. 

What  is  the  prognosis? 

If  untreated,  spontaneous  cure  is  possible  by  rupture  and  absorp- 
tion of  the  fluid  :  50  per  cent,  of  cases  rupturing  and  untreated  are, 
however,  fatal :  or  by  calcareous  degeneration  ;  but  cure  in  this  way 
is  extremely  rare.  The  ordinary  course  is  for  the  tumor  to  go  on 
increasing  in  size,  and  finally  to  cause  death  in  one  of  the  following 
ways:  (1)  Eupture  of  cyst  (with  or  without  suppuration)  and 
production  of  peritonitis.  (2)  Inflammation  of  the  cyst-wall,  filling 
the  cyst  with  pus  :  finally  septic  infection,  and  death.  (3)  Twi.st- 
ing  or  rupture  of  the  pedicle,  gangrene  of  the  cyst,  septicaemia. 
(4)  Prolonged  interference  with  the  nutrition  and  respiration.  (5) 
Acute  or  chronic  peritonitis,  rapid  or  slow  exhaustion.  (6)  Fatal 
hemorrhage  into  the  cyst..     (7)  Simply  gradual  exhaustion. 

Enumerate  the  conditions  from  which  a  small  ovarian  cyst  in  the 
pelvic  cavity  must  be  diagnosed. 

Solid  ovarian  tumors ;  cysts  of  the  broad  ligaments ;  distended 
tubes ;  normal  pregnancy ;  normal  pregnancy  with  retroversion ; 
extra-uterine  gestation  ;  fibroid  tumors  of  the  uterus  ;  uterine  moles  ; 
peritonitic  exudation  or  abscess  ;  inflammatory  exudation  in  the 
broad  ligament ;  pelvic  haematocele  ;  spina  bifida  ;  faecal  accumula- 
tions ;  inflammation  of  the  vermiform  appendix ;  tumors  of  the 
pelvic  walls. 

Grive  the  differentiation  from  a  distended  tube. 

Histryry. — This  condition  begins  with  the  symptoms  of  an  acute 
inflammation,  negative  in  the  case  of  an  ovarian  cyst. 

Shape. — Tubal  elongated,  ovarian  globular. 

Relation. — Tubal  m'ore  intimate  to  uterus  than  in  the  case  of 
ovarian  cyst. 

Sensitiveness. — Tubal  marked,  ovarian  slight. 


180  DISEASES   OF   THE   OVARIES. 

Contents. — Straw-colored  in  hydrosalpinx,  and  pus  in  pyosalpinx  ; 
in  ovarian  cyst  as  above  described. 

Give  the  differentiation  from  peritonitic  exudation  or  abscess. 

History  of  acute  inflammation,  fixation,  less  rounded  outline, 
and  less  distinct  fluctuation  ;  pus  found  on  puncture  when  fluctua- 
tion does  exist.  Sensitiveness,  usually  in  Douglas's  pouch,  while 
an  ovarian  cyst  is  commonly  lateral. 

Give  the  differentiation  from  an  exudation  into  the  broad  ligament. 

History  of  inflammation  after  some  operation  or  after  labor  or 
abortion.  Haematoma  would  give  a  history  of  sharp  pain  with 
more  or  less  prostration  and  rapid  development  of  the  tumefaction  ; 
fixity  and  tenderness. 

Give  the  differentiation  from  extra-uterine  gestation. 

Rapidity  of  growth  and  the  presence  of  many  of  the  signs 
(morning  sickness,  changes  in  the  breasts  and  vagina,  etc.)  of 
normal  pregnancy  ;  amenorrhoea  followed  by  irregular  menorrhagia 
(in  ovarian  cyst  menstruation  is  little  aflected) ;  increase  in  size  of 
the  uterus  ;  greater  fixity  of  the  tumor  ;  pain  from  recurrent  attacks 
of  acute  peritonitis ;  finally  symptoms  of  rupture  (pain,  shock,  col- 
lapse, and,  if  untreated,  death  from  hemorrhage  or  peritonitis). 

Enumerate  the  conditions  from  which  a  large  ovarian  cyst  in  the 
abdominal  cavity  must  be  differentiated. 

Solid  Ahdominal  Tumors. — Of  the  anterior  abdominal  wall  (des- 
moids) ;  of  the  omentum  ;  of  the  spleen,  kidney,  or  liver ;  of  the 
ovary  or  uterus  (fibroid  or  fibro-cystic) ;  of  the  retro-peritoneal 
connective  tissue. 

Cystic  Tumors. — Of  the  omentum  or  mesentery ;  of  the  liver, 
pancreas,  or  kidney ;  of  the  broad  ligament ;  parasitic  cysts  (hyda- 
tid, etc.)  ;  hajmatometra  ;  vesicular  mole  ;  hydrosalpinx. 

Pregnancy. — Normal ;  with  dropsy  of  the  amnion  ;  abdominal 
pregnancy. 

Ascites. — Simple  ;  encysted  ;  tubercular  peritonitis  ;  tympanites  ; 
phantom  tumor ;  distension  of  bladder  or  stomach. 

Give  the  differentiation  from  ascites. 

In  this  the  abdomen  is  flatter  in  the  recumbent  position,  and 
convex  when  standing.  If  the  patient  turn  over,  the  relation  of 
the  areas  of  tympanitic  resonance  to  the  area  of  fluid  flatness 
changes.     There  is  a  perfect  wave  of  fluctuation  transmitted  across 


NEOPLASMS   OF   THE   OVARY.  181 

the  abdomen.  No  encysted  or  circumscribed  wave  can  be  made 
out,  and  there  is  generally  a  history  of  some  cause  (as  renal  or 
hepatic  disease,  etc.)  to  account  for  it. 

Give  the  diflferentiation  from  normal  pregnancy. 

This  would  give  the  regular  changes  in  the  breasts,  vagina, 
cervix,  etc.,  presence  of  ballottement,  uterine  bruit,  foetal  heart- 
sounds  ;  perhaps  foetal  parts  may  be  made  out  on  palpation  ;  rhyth- 
mic uterine  contractions  ;  absence  of  fluctuation  and  of  the  haggard 
expression  characteristic  of  ovarian  cyst.  Amenorrhoea  is  not 
positive  evidence,  but  probable. 

Give  the  differentiation  from  distension  of  the  bladder. 

The  introduction  of  a  catheter  and  the  immediate  disappearance 
of  the  swelling  are  conclusive. 

Give  the  differentiation  from  uterine  fibroids  and  fibro-cysts. 

A  fibro-cyst  of  the  uterus  cannot  be  positively  diagnosed  from 
an  ovarian  cyst  except  by  exploratory  laparotomy.  A  fibroid 
would  give  a  history  of  slow  development,  menorrhagia,  uterine 
souffle,  close  connection  with  the  uterus,  increased  general  deposit 
of  fat,  and  some  pigmentation  of  the  skin,  as  in  pregnancy ;  uterine 
cavity  increased  in  length. 

Detail  the  treatment  of  ovarian  cysts. 

Curative. — Removal  by  laparotomy. 

Palliative. — Evacuation  of  cyst-contents  by  aspiration  or  tap- 
ping. 

The  procedures  indicated  under  the  second  heading  have  many 
objections,  and  are  resorted  to  only  when,  as  in  pregnancy,  the 
tumor  gives  rise  to  urgent  pressure  symptoms,  and  a  resort  to  the 
major  operation  seems  too  risky. 

CYSTS  OF  THE  BROAD  LIGAMENT,  OR  PAROVARIAN  CYSTS. 

Describe  these  cysts. 

They  develop  between  the  layers  of  the  broad  ligament  in  the 
parovarium  or  organ  of  Rosenmtiller,  which  is  a  remnant  of  the 
foetal  Wolffian  body.  They  are  always  monocystic,  and  tend  to 
grow  down  into  the  pelvis,  and  only  into  the  abdominal  cavity  after 
they  have  attained  considerable  size.  They  grow  more  slowly  than 
ovarian  tumors,  and  have  no  marked  eiFect  upon  the  general  health. 

The  best  treatment  is  laparotomy,  incision  of  cyst,  evacuation  of 


182  DISEASES   OF   THE   OVARIES. 

contents,  excision  of  the  excess  of  cyst-wall,  suture  of  cyst-wall  in 
the  abdominal  wound,  and  packing  with  iodoform  gauze. 

LAPAROTOMY  FOR  THE  REMOVAL  OF  THE  UTERINE 
APPENDAGES  OR  OF  CYSTS. 

Ovariotomy. 

What  instruments  are  required? 

Scalpel ;  mouse-tooth  forceps,  2 ;  dissecting  forceps,  2 ;  Tait's 
clamps,  small,  6 ;  large,  6 ;  right  aneurism  needles,  4 ;  left,  1  ; 
uterine  sound  ;  scissors,  curved,  straight,  angular  ;  double  volsella,  3; 
trocar  and  canula  ;  artery  clamps,  12;  Paquelin  cautery;  needles, 
long,  curved,  spear-pointed,  6 ;  medium,  curved,  spear-pointed,  6 ; 
small  Hagedorn,  6. 

Also  the  following  materials :  silk,  heavy  floss  or  braided  for 
pedicles  ;  finer  for  sutures  and  carrying  wire  sutures  ;  catgut,  Nos. 
2  and  3 ;  silver  wire,  No.  24 ;  glass  drainage-tubes ;  antiseptic  dress- 
ings. 

What  are  the  steps  of  the  operation  ? 

The  bladder  and  rectum  have  been  evacuated  shortly  before,  and 
no  solid  food  has  been  taken  for  five  hours  preceding  the  operation. 
The  patient  lies  upon  her  back  upon  a  flat  operating  table,  or 
Trendelenberg's  table  may  be  used. 

First  Step. — Preparation  of  the  field  of  operation.  The  pubes 
is  shaved  and  the  abdomen  scrubbed  with  soft  soap  and  warm 
water ;  it  is  then  wiped  ofl"  with  alcohol,  turpentine,  ether,  and 
bichloride  of  mercury  1  :  1000.  Wet  bichloride  towels  are  spread 
about.* 

^  Instruments  have  been  sterilized  by  boiling  in  a  1  per  cent,  solution  of 
carbonate  of  soda,  and  are  kept  in  carbolic  acid  1  :  40;  hands  and  forearms 
of  operator  and  assistants  have  been  disinfected  by  scrubbing  with  soap  and 
water,  followed  by  alcohol  and  bichloride.  Silk  and  silver  wire  are  pre- 
pared by  boiling.  Catgut  is  prepared  by  immersion  for  eight  hours  in  ether, 
eight  hours  in  bichloride,  1  :  1000,  and  then  in  several  changes  of  alcohol, 
in  which  it  is  finally  stored.  A  most  desirable  addition  is  the  final  boiling 
in  alcohol  for  one  hour  over  a  water-bath  ;  a  condenser  may  be  used  to  pre- 
vent loss  of  alcohol.  Chromicized  catgut  is  prepared  by  washing  in  alcohol 
and  then  immersing  for  forty-eight  hours  in  water  100  parts,  carbolic  acid 
5  parts,  and  bichromate  of  potash  0.2  parts:  it  will  not  be  absorbed  by  the 
tissues  for  a  week,  and  is  used  for  ligatures  (as  on  pedicles)  where  thi?. 
property  of  non-absorbability  renders  it  valuable. 


LAPAROTOMY.  183 

Second  Step. — Incision  in  the  median  line  between  the  umbilicus 
and  the  symphysis  of  an  average  length  of  four  or  five  inches. 
The  tissues  are  divided  layer  by  layer,  and  hemorrhage  is  checked 
before  the  peritoneum  is  opened.  A  fold  of  peritoneum  is  held  up 
by  two  mouse-toothed  forceps  and  nicked ;  a  grooved  director  is 
then  introduced,  and  the  peritoneum  divided  with  scalpel  or  scissors, 
or  the  fingers  may  take  the  place  of  the  grooved  director. 

Third  Step. — Tapping  the  cyst  (for  tubal  disease  or  solid  tumors 
of  course  this  would  be  unnecessary).  Emmet's  long  curved  trocar 
and  canula  are  used  ;  abdominal  compression  is  made  as  the  contents 
escape  ;  an  effort  is  made  to  prevent  the  entrance  of  even  a  single 
drop  of  the  fluid  into  the  abdominal  cavity  ;  the  aperture  is  clamped 
as  the  canula  is  withdrawn. 

Fourth  Step. — Drawing  out  the  sac.  This  is  done  with  volsella 
and  gentle  traction  with  the  fingers.  Adhesions  to  the  abdominal 
wall,  omentum,  large  intestine,  and  mesocolon  may  be  found,  and 
less  frequently  to  the  small  intestine,  bladder,  liver,  diaphragm,  and 
the  walls  of  pelvis.  These  are  either  gently  separated  or  are  ligated 
and  divided :  their  treatment  constitutes  the  only  difficulty  in  the 
operation. 

Fifth  Step. — Securing  the  pedicle.     This  is  best  done  by  com- 
pressing the  pedicle  with  any  suitable  clamp, 
cutting  off  the  tumor,  ligating  the  pedicle  Fig  84. 

by  the  Staffordshire  knot  (Fig.  84),  cauter- 
izing the  cut  surface  with  the  Paquelin 
cautery,  removing  the  clamp,  and  allowing 
the  pedicle  to  fall  into  the  pelvis.* 

Sixth  Step. — Peritoneal  toilet.  All  hemor- 
rhage has  been  checked,  and  in  ordinary 
cases  it  is  necessary  simply  to  lightly  sponge  Staffordshire  Knot, 

out  the  pelvic  and  abdominal  cavities  with 

sponges  on  holders.  In  other  cases,  where  trouble  is  feared  from 
access  of  the  fluid  to  the  peritoneum,  the  entire  peritoneal  cavity  is 
flushed  out  repeatedly  with  sterilized  water  or  Thiersch's  solution 
at  a  temperature  of  100°  F. 

*  The  Staffordshire  knot  is  tied  as  follows :  pass  a  strong  straight  needle, 
threaded  double  with  heavy  pedicle  silk,  through  the  pedicle  and  under  the 
clamp.  Then  pull  the  loop  through  and  remove  the  needle.  Now  pass 
both  the  clamp  with  the  distal  extremity  of  the  pedicle  and  one  of  the 
loose  ends  of  the  ligature  through  the  loop  by  drawing  the  loop  forward. 
Then  draw  each  end  tight,  and  tie  very  tightly  a  square  knot. 


184  DISEASES   OF   THE   OVARIES. 

Seventh  Step. — Drainage.  A  glass  drainage-tube  is  introduced 
at  the  lower  angle  of  the  wound,  and  reaches  down  into  Douglas's 
pouch ;  it  is  lightly  filled  with  iodoform  gauze.  Drainage  may 
often  be  omitted. 

Eighth  Step. — Suture  and  antiseptic  dressing.  The  suture  may 
pass  through  all  layers  at  once,  or  the  peritoneum,  the  muscles, 
the  fascia,  and  the  skin  may  be  sutured  separately. 

After-treatment. — Absolute  rest  in  bed ;  an  eighth  of  a  grain  of 
morphine  hypodermically  is  often  sufficient  to  control  pain  and 
restlessness.  The  packing  in  the  tube  is  removed  in  three  hours, 
and  such  fluid  (bloody  serum)  as  has  accumulated  is  sucked  out 
by  a  syringe  with  a  long  rubber  tube  attached ;  fresh  packing. 
This  is  repeated  at  least  once  in  three  hours,  and  the  tube  is 
commonly  removed  in  twenty-four  hours  or  less.  Vomiting  is 
prevented  by  not  giving  anything  by  the  mouth  for  six  or  twelve 
hours  after  operation.  The  bowels  should  be  moved  in  forty -eight 
hours.  Sutures  are  removed  at  about  the  ninth  day,  and  in  three 
weeks  the  patient  is  commonly  well. 

Battey's  Operation,  or  Oophorectomy. 
Describe  this  operation. 

It  is  the  removal  of  the  normal  or  not  very  greatly  changed 
ovaries  for  the  relief  of  symptoms  which  do  not  yield  to  other 
treatment.  The  indications  for  it  are — uterine  fibroids  (to  check 
their  growth),  chronic  pelvic  inflammations,  chronic  ovaritis  and 
ovaralgia,  ovarian  insanity,  ovarian  epilepsy  (of  course  only  in 
carefully  considered  and  selected  cases). 

The  details  of  the  operation  are  the  same  as  those  of  ovariotomy, 
except  that  the  ovary  is  simply  brought  up  into  the  wound  by  tfi^ 
fingers  and  seized  by  fenestrated  forceps :  its  pedicle  is  transfixed 
by  a  double  ligature,  tied,  cut  away,  and  allowed  to  drop  back  into 
the  pelvis :  the  cut  surface  may  be  touched  with  the  Paquelin 
cautery. 

Tait's  Operation. 
Describe  this  operation. 

It  is  the  removal  of  ovaries  and  tubes  for  the  same  conditions  as 
Battey's  operation.  It  involves  as  an  additional  step  ligature  of 
the  broad  ligament  in  sections  before  the  ovary  and  tube  can  be 
cut  away. 


DISEASES   OF   THE   FALLOPIAN   TUBES.  185 

DISEASES  OF  THE  FALLOPIAN  TUBES. 

SALPINGITIS. 
Describe  salpingitis. 

The  acute  variety  is  commonly  the  extension  of  a  gonorrhoeal 
inflammation  of  the  lower  genital  tract.  It  may,  as  latent  gonor- 
rhoea in  the  female  (Noeggerath),  be  a  very  common  cause  of 
sterility,  and  may  be  acquired  from  a  very  old  and  aj)parently  cured 
gonorrhoea  in  the  male.  Acute  salpingitis  may,  however,  occur 
without  venereal  infection.  Chronic  salpingitis  may  follow  an 
acute  attack  or  may  develop  gradually  of  itself. 

What  is  its  pathology  ? 

The  mucous  membrane  is  thickened  and  thrown  into  ridges ; 
the  inflammation  extends  to  the  peritoneal  coat,  and,  from  cicatricial 
contraction  and  pressure  and  traction  by  adhesions,  deformity  and 
stricture  of  the  tube  may  result,  the  lumen  at  each  extremity  may 
be  obliterated,  and  a  collection  of  the  hypersecretion  of  the  mucous 
membrane  may  take  place.  The  condition  is  termed  hydrosalpinx, 
pyosalpinx,  or  hsematosalpinx  according  as  the  contents  of  the 
distended  tube  are  clear,  limpid  fluid,  pus,  or  principally  blood. 

What  are  the  causes  of  salpingitis  ? 

Gonorrhoeal  infection,  septic  infection  from  other  causes,  expo- 
sure during  menstruation. 

What  are  the  symptoms  ? 

Acute  salpingitis  :  Sharp  pain  in  one  or  both  sides  of  the  pelvis  ; 
moderate  rise  of  temperature  ;  tenderness  in  the  region  of  the  tube, 
which  may  sometimes  be  felt  on  bimanual  examination. 

Chronic  salpingitis  :  Menstrual  colic  ;  leucorrhoeal  discharge.  On 
bimanual  examination  the  tube  can  commonly  be  felt  to  be  thick- 
ened and  irregular. 

What  is  the  treatment? 

Acute  salpingitis :  Rest  in  bed ;  antiphlogistics  (ice  over  hypo- 
gastrium  or  prolonged  hot  vaginal  douches) ;  leeches  perhaps ; 
blisters. 

Chronic  salpingitis  :  Repeated  blisters  over  iliac  region  ;  counter- 
irritants  to  the  fornix  of  the  vagina ;  tampons  of  boroglyceride,  or 
8  per  cent,  ichthyol  in  glycerin ;  hot  douches ;  alterative  sitz- 
baths  (warm  solution  of  sea-salt,  etc.)  ;  galvanic  current ;  salpingo- 


186  HEMATOSALPINX. 

oophorectomy  if  the  symptoms  are  sufficiently  urgent  and  persist 
in  spite  of  treatment. 

What  are  the  special  features  of  hydrosalpinx  ? 

History  of  catarrhal  salpingitis  and  very  mild  pelvic  peritonitis ; 
symptoms  of  pain  and  pelvic  pressure.  A  tense,  smooth,  elastic 
oval  mass  is  felt  in  Douglas's  pouch  ;  it  may  be  fixed  or  movable. 
Clear  fluid  is  drawn  on  aspiration  per  va^mam.  The  disease 
seldom  threatens  life. 

Treatment  is  either  by  evacuation  per  vaginam  or  removal  of 
ovary  and  tube  by  laparotomy. 

PYOSALPINX. 

What  are  the  special  features  of  pyosalpinx  ? 

In  consequence  of  repeated  attacks  of  salpingitis  both  extremities 
of  the  tube  have  become  impermeable,  and  the  cavity  is  distended 
with  several  ounces  of  pus.  The  symptoms  are  those  of  recurrent 
pelvic  peritonitis,  with  freedom  from  pain  between  the  attacks. 
A  tense,  fluctuating,  rather  fixed,  mass  is  felt  in  Douglas's  pouch, 
which  on  aspiration  yields  pus.  Dangers  are  of  rupture  into  the 
peritoneal  cavity,  but  this  is  commonly  prevented  by  adhesions. 

Treatment  is  in  most  cases  best  by  removal  of  ovary  and  tube 
by  laparotomy.  Where  the  abscess  is  opened  through  the  vagina 
and  drained  or  packed  it  is  very  difficult  to  bring  about  oblitera- 
tion of  the  cavity.  ** 

HJEMATOSALPINX. 

What  are  the  special  features  of  hsematosalpinx  ? 

The  tube  is  distended  with  fluid  blood  from  rupture  of  a  tubal 
pregnancy,  from  the  regular  monthly  hemorrhage  from  the  mucous 
membrane  of  the  tube,  or  from  regurgitation  from  the  cavity  of 
the  uterus.  Symptoms  are  pain  and  pressure.  Even  when  its 
production  is  sudden,  the  amount  of  blood  taken  from  the  general 
circulation  is  not  enough  to  give  the  symptoms  of  anaemia.  The 
chief  danger  is  of  intraperitoneal  rupture. 

Treatment  is  removal  of  ovary  and  tube  by  laparotomy,  or,  if  the 
cavity  be  intraligamentous,  not  a  true  hoematosalpinx,  incision  and 
drainage  from  the  vagina. 


EXTRA-UTERINE   PREGNANCY.  187 

LAPAROTOMY  FOR  PYOSALPINX,  ETC.—"  SALPINGO- 

OOPHORECTOMY. ' ' 

This  operation  differs  from  ovariotomy  in  the  fact  that  both  tube 
and  ovary  on  the  affected  side  are  removed,  and  that  it  is  thus  neces- 
sary to  ligate  the  broad  ligament  in  sections  before  cutting  the  tube 
away. 

EXTRA-UTERINE  PREGNANCY. 

What  are  the  principal  varieties  ? 

Tubal,  interstitial,  and  abdominal  pregnancy. 

What  are  the  causes? 

Stricture  of  the  tube ;  constriction  or  flexion  of  the  tube  by 
adhesions  ;  tumefaction  of  the  mucous  membrane  of  the  tube  from 
chronic  salpingitis. 

What  are  the  symptoms? 

For  the  first  two  or  three  months  there  are  amenorrhoea  and  th.e 
ordinary  symptoms  of  pregnancy.  Then  the  patient  may  suddenly 
exhibit  the  symptoms  of  pelvic  haematocele:  intense  pain,  nausea, 
and  collapse ;  if  untreated,  death  may  follow  from  acute  anaemia 
or  septic  peritonitis,  or  a  slow  recovery  may  take  place.  In  other 
cases  the  symptoms  which  first  attract  attention  are  irregular  and 
profuse  discharges  of  blood  from  the  uterus,  pain,  and  a  rapid 
enlargement  of  the  hypogastrium. 

What  are  the  physical  signs? 

The  uterus  is  distinctly  enlarged  and  softened,  and  is  displaced 
upward  and  to  one  side.  Its  cavity  is  slightly  increased  in  length, 
and  on  dilatation  of  the  cervix  it  is  proven  to  be  empty.  In 
Douglas's  pouch  or  a  little  to  one  side  a  tumor  may  be  felt :  it  is 
rather  fixed,  not  very  sensitive,  fluctuating,  and  sometimes  gives 
ballottement. 

What  is  the  diagnosis? 

It  must  be  differentiated  from  uterine  fibroids  or  fibro-cysts  ;  cyst 
of  the  ovary  or  broad  ligament ;  pelvic  hsematocele ;  gestation  in 
one  horn  of  uterus  bicornis ;  pregnancy  in  a  retroverted  uterus ; 
pelvic  inflammatory  exudation  or  abscess. 

What  are  the  course  and  prognosis? 

The  prognosis  is    bad.     If   untreated,   rupture   sooner   or  later 


188    DISEASES  OF  THE  PELVIC  PERITONEUM  AND  FASCIJE. 

occurs  in  almost  all  cases,  and  death  may  then  occur  from  hemor- 
rhage, septicaemia,  peritonitis,  and  perforation  of  important  viscera  ; 
or  the  haematocele  thus  produced  may  terminate  favorably,  and  the 
foetus,  now  dead,  may  be  converted  into  a  lithopsedion  and  may  give 
no  further  trouble,  though  it  is  always  liable  to  do  so. 

What  is  the  treatment? 

For  a  ruptured  extra-uterine  gestation  there  is  only  one  thing 
to  be  done :  laparotomy  and  removal  of  the  sac  and  its  contents. 
Unruptured  cases  may  properly  be  first  treated  by  methods  calcu- 
lated to  destroy  the  life  of  the  foetus,  and  hence,  by  reduction  of 
vascularity,  the  subsequent  removal  may  be  very  much  less  dan- 
gerous. These  methods  are — electricity  (faradic  current,  one  pole 
placed  either  in  the  vagina  or  rectum  ;  sittings  repeated  until  the 
sac  ceases  to  grow :  it  would  be  worse  than  useless  if  there  were 
any  symptoms  of  impending  rupture).  Aspiration  of  the  amniotic 
fluid  was  formerly  performed ;  also  the  injection  of  different  sub- 
stances into  the  sac ;  but  these  have  been  abandoned. 

In  cases  of  distinctly  abdominal  pregnancy  which  have  passed 
the  first  three  or  four  months,  interference  should  be  withheld 
until,  at  about  full  term,  an  attempt  at  labor  gives  the  indication 
for  laparotomy,  with  a  moderate  chance  for  both  mother  and  child. 

DISEASES  OF  THE  PELVIC  PERITONETJM  AND 

FASOIiB. 

PELVIC  PERITONITIS. 

Define  and  give  the  synonyms. 

Pelvic  peritonitis  is  an  inflammation  of  that  portion  of  the 
general  peritoneum  which  lines  the  pelvis  and  invests  the  pelvic 
viscera.  It  is  one  of  the  most  common  diseases.  The  synonyms 
are  perimetritis  and  pelveo-peritonitis. 

Describe  the  pelvic  peritoneum. 

From  before  backward  it  is  reflected  on  to  the  bladder  from  the 
anterior  abdominal  wall  about  1^  inches  above  the  symphysis; 
covers  the  fundus,  and  crosses  to  the  uterus  on  a  level  with  the 
OS  internum,  forming  the  vesico-uterine  pouch  and  vesico-uterine 
ligaments.  The  vesico-uterine  pouch  is  normally  empty,  and  lies 
more  than  ^  an  inch  above  the  anterior  fornix  of  the  vagina.  The 
jteritoneum  invests  closely  the  anterior  surface  of  the  uterus,  passes 


PELVIC    PERITONITIS. 


189 


over  the  fundus,  and  covers  the  entire  posterior  surface.  Laterally 
it  passes  off  to  the  sides  of  the  pelvis,  forming  the  broad  ligaments. 
Posteriorly  it  continues  down,  investing  the  vaginal  wall  for  about 

Fig.  85. 


Pelvic  Peritoneum,  indicated  by  dark  line,  PP,  which  does  not  extend  sufficiently 

between  U  and  B. 


an  inch ;  passes  on  to  the  rectum,  forming  the  pouch  or  cul-de-sac 
of  Douglas  and  the  utero-sacral  ligaments.  It  covers  the  anterior 
surface  of  the  middle  portion  of  the  rectum,  and  completely  sur- 
rounds the  upper  part. 


190    DISEASES  OF  THE  PELVIC  PERITONEUM  AND  FASCIJE. 

What  fossae  are  formed  by  reflections  of  the  pelvic  peritoneum? 

The  utero-vesical  in  front  and  two  lateral  pouches,  the  para- 
vesical ;  the  pouch  of  Douglas  behind,  and  two  lateral  pouches  just 
outside  the  utero-sacral  ligaments. 

The  pouch  of  Douglas  is  the  lowest  part  of  the  pelvic  peri- 
toneum. It  is  the  first  part  to  be  filled  with  fluid,  and  may  contain 
loops  of  intestine  or  tumors,  ovaries,  etc.  It  is  separated  from  the 
vagina  by  only  one-fourth  of  an  inch  of  tissue,  and  extends  down  a 
little  deeper  on  the  left  side. 

What  is  the  pathology  of  pelvic  peritonitis  ? 

Pelvic  peritonitis  is  usually  localized.  The  serous  membrane 
first  loses  its  shiny,  glistening  appearance  from  loss  of  epithelium 
and  from  exudation.  If  there  is  a  slight  amount  of  fluid,  the 
surfaces  may  adhere  to  each  other ;  if  the  serum  is  considerable, 
adhesions  may  be  prevented  and  the  fluid  absorbed  ;  or  it  may  be 
encapsulated,  forming  peritoneal  cysts.  The  inflamed  surfaces 
are  covered  with  a  reddish-yellow  pseudo-membrane,  consisting 
chiefly  of  newly-formed  connective  tissue  (plastic  lymph),  which 
may  be  so  profuse  as  to  fill  up  all  the  cracks  and  cause  adhesion 
of  all  the  viscera. 

In  severe  forms,  such  as  are  produced  from  puerperal  septicsemia 
and  gonorrhoea,  the  fluid  becomes  purulent.  The  varieties  of  pelvic 
peritonitis  are — adhesive 2)erltomtis,  sero-adhesiv^eritonitis, purulent 
peritonitis. 

What  is  the  etiology? 

Pelvic  peritonitis  is  generally  secondary  to  inflammation  of  the 
uterus,  ovaries,  and  tubes,  and  these  are  generally  induced  by — 

1.  Taking  cold  during  menstruation,  first  giving  rise  to  endo- 
metritis, then  salpingitis,  and  finally  peritonitis. 

2.  Gonorrhoea. 

3.  Traumatism,  passage  of  sound,  applications  to  the  cervix 
having  been  known  to  cause  peritonitis. 

4.  Septic  infection  by  instruments  or  during  parturition  and 
abortion. 

5.  Entrance  of  foreign  substances  into  the  pelvic  cavity ;  rup- 
ture of  a  pyosalpinx  or  ovarian  abscess,  or  injection  of  fluids 
through  the  uterus  and  tubes  ;  hoematocele. 

6.  Mechanical  irritation  ;  displaced  uterus  or  ovary  ;  improperly 
applied  pessary. 


PELVIC   CELLULITIS   OR   PARAMETRITIS.  191 

7.   New  growths  ;  cancer  ;   tubercular  peritonitis. 

Pelvic  cellulitis.  Owing  to  the  intimate  anatomical  connection 
of  the  pelvic  fascia  and  peritoneum  usually  both  inflammations 
result  from  the  same  cause. 

What  are  the  symptoms? 

These  may  be  acute  or  chronic. 

Acute:  Sharp  chill;  temperature  not  high,  101°-102° ;  rapid 
pulse,  120  or  more ;  pain  and  tenderness  in  lower  part  of  abdomen  ; 
knees  drawn  up  ;  tongue  furred  early  ;  nausea  and  vomiting ;  con- 
stant desire  to  pass  water ;  severe  rectal  and  vesical  tenesmus ; 
constipation  ;  tympanites  ;  sometimes  menorrhagia.  Temperature 
may  rise  later  to  105°  or  106°,  with  general  involvement  of  the 
peritoneum ;  but  the  inflammation  usually  subsides  in  a  few  days, 
or  becomes  chronic,  or  goes  on  to  the  formation  of  an  abscess. 

Chronic :  The  symptoms  of  the  subacute  and  chronic  form  may 
be  very  indefinite,  and  at  first  unrecognized.  The  whole  pelvic 
contents  may  be  massed  together  without  any  symptoms.  There 
are  usually  dull  aching  pain  in  the  pelvis,  dyspareunia,  menor- 
rhagia, and  metrorrhagia.  The  pain  may  be  intermittent  in  cha- 
racter, but  all  the  symptoms  may  be  remittent,  with  exacerbations. 
Obstinate  constipation,  with  rectal  and  vesical  tenesmus,  is  a  com- 
mon symptom. 

What  are  the  physical  signs? 

Tenderness  on  pressure  in  the  fornices ;  utero-sacral  ligaments 
thickened,  tender,  and  feeling  like  tense  cords  behind  the  cervix. 
The  uterus  may  be  fixed  by  adhesions.  When  the  exudation  of 
plastic  lymph  is  considerable,  we  may  get  the  "  cardboard  feel,"  in 
which  the  fornices  feel  hard  and  resistant,  as  if  plaster  of  Paris  had 
been  poured  into  the  pelvis  and  hardened.  When  there  is  con- 
siderable serum  or  pus  shut  ofi"  by  adhesions,  it  may  form  a  tumor 
behind  the  uterus  and  bulge  into  the  vagina. 

What  are  the  complications? 

Diseases  of  the  uterus,  ovaries,  tubes,  bladder,  and  rectum ; 
displacements  of  the  uterus  and  ovaries ;  stenosis  and  inflammation 
of  the  tubes,  resulting  in  sterility ;  extra-uterine  pregnancy ;  dis- 
turbances of  menstruation. 

What  is  the  prognosis? 

Mild  cases  may  exist  for  life  and  give  no  discomfort,  or  may 
gradually    disappear.      Large    plastic    exudations    disappear    very 


192    DISEASES  OF  THE  PELVIC  PERITONEUM  AND  FASCIA. 

slowly,  and  result  in  displacements.  Serum  may  be  absorbed  or 
go  on  to  suppuration.  Pus,  more  grave,  may  become  encapsulated 
or  rupture  into  neighboring  organs,  or  give  rise  to  septicaemia, 
pyaemia,  and  death. 

What  is  the  differential  diagnosis? 

The  low  temperature  may  distinguish  it  from  cellulitis.  It  must 
be  differentiated  from  fibroid  tumors,  faecal  impaction,  and  pelvic 
haematocele.     The  history  will  in  most  cases  suffice. 

What  is  the  treatment? 

Acute  cases :  Absolute  rest  in  bed ;  give  enough  opium  or  mor- 
phine to  relieve  the  pain  ;  limit  the  inflammation  by  an  ice-bag  or 
coil  on  the  abdomen  ;  later,  apply  hot  poultices  to  the  abdomen, 
and  give  hot  vaginal  injections ;  move  the  bowels  by  calomel  and 
an  enema. 

Chronic  cases :  Attend  to  the  general  health  by  the  administra- 
tion of  tonics,  fresh  air,  exercise,  and  keeping  the  bowels  well 
regulated. 

Hot  douches ;  tampons  of  glycerin  or  ichthyol  in  glycerin  5  per 
cent,  to  8  per  cent. ;  painting  the  fornices  with  iodine.  For  the 
adhesions,  properly  applied  manage  or  electricity  sometimes  acts 
very  well.  Blisters  in  the  iliac  regions  are  sometimes  used.  The 
following  prescription  is  excellent  for  keeping  the  bowels  regulated 
in  these  cases : 

II.  Extract,  cascara  sagrad.,  fl.,  ^ss  ; 

Tr.  nucis  vomic,  Rv; 

Tr.  belladon.,  n|^iij  ; 

Glycerin.,  ^x; 

Aqua  menth.  pip.  q.  s.,  gj. — M. 
Ft.sj. 

When  there  is  a  collection  of  pus  with  no  signs  of  pointing,  it 
must  be  evacuated  and  drained.  This  may  be  done  through  the 
vagina  or  abdominal  wall. 

PELVIC   CELLULITIS   OR  PARAMETRITIS. 

What  is  the  function  of  cellular  tissue  ?  and  where  is  it  found  ? 

It  acts  as  a  buffer  and  steadies  the  pelvic  organs  ;  it  binds  the 
organs  together.  It  is  found  between  the  bladder  and  the  abdomi- 
nal wall  (the  prevesical  space  of  Retzius)  ;  in  front  of  the  cervix ) 


PELVIC   CELLULITIS   OR   PARAMETRITIS.  193 

behind  the  uterus  ;   between  the   layers  of  the  broad  ligaments  ; 
in  the  utero-sacral  ligaments. 

What  are  the  etiology  and  pathology  of  parametritis  ? 

The  causes  are — (1)  Septic  infection,  usually  from  childbirth  or 
abortions  (especially  criminal)  ;  (2)  operations  on  the  cervix ; 
(3)  pelvic  peritonitis ;  (4)  cancerous  or  syphilitic  disease. 

The  pafhological  stages  are — (1)  Engorgement  of  the  blood- 
vessels ;  (2)  exudation  of  serum,  leucocytes,  and  plastic  lymph  ; 
(3)  the  exudation  may  resolve,  or  less  frequently  go  on  to  the 
formation  of  pus,  or  it  may  form  new  connective  tissue  and 
remain. 

Cellulitis  usually  begins  in  the  bases  of  the  broad  ligaments,  and 
extends  from  there.  When  pus  forms,  it  usually  extends  around 
to  the  prevesical  space  of  Retzius,  or  it  may  go  posteriorly.  Re- 
cent investigation  has  shown  that  most  of  the  cases  formerly 
supposed  to  be  cellulitis  are  really  peritonitis  and  salpingitis. 

What  are  the  complications? 

Pelvic  peritonitis  always  complicates  cellulitis,  but  cellulitis  is 
not  necessarily  present  with  peritonitis.  Inflammation  of  the 
ovaries  and  tubes ;  displacements  of  the  uterus  ;  thrombosis  of  the 
veins. 

What  is  the  course? 

In  cellulitis  resulting  from  criminal  abortions  or  parturition  the 
exudation  mass  may  be  absorbed  in  two  or  three  weeks,  or  it  may 
remain  months  and  years  and  become  chronic.  It  may  go  on  to  the 
formation  of  pus,  and  the  abscess  thus  formed  may  rupture  into  rec- 
tum, vagina,  or  bladder,  or  the  pus  may  follow  the  inguinal  canal 
and  form  a  labial  abscess.  Rarely  it  discharges  through  the  sacro- 
sciatic  or  obturator  foramen,  or  into  the  peritoneal  cavity.  The 
abscess  may  then  heal  up  from  the  bottom  or  continue  discharg- 
ing indefinitely. 

What  are  the  ssrmptoms  ? 

Acute :  These  usually  appear  on  the  third  to  the  fifth  day  after 
labor  or  abortion  :  Rigor,  fever  up  to  103°-105°  ;  sthenic  pulse  ; 
pain  not  in  proportion  to  the  symptoms ;  leg  drawn  up  on  the  side 
where  the  pain  is  ;  nausea,  but  rarely  any  vomiting ;  some  irrita- 
bility of  the  bladder  and  rectum.  (When  pus  forms  there  will  be 
septic  symptoms  and  cessation  of  lochial  discharge.)     These  symp- 

13— Gyn, 


194    DISEASES  OF  THE  PELVIC  PERITONEUM  AND  FASCIA. 

toms  subside  in  a  few  days  and  the  patient  gets  well,  or  the  disease 
goes  into  the  chronic  form  or  forms  an  abscess. 

Chronic  :  Onset  insidious.  Patients  may  go  about  with  a  large 
exudation  mass,  experiencing  only  a  heavy  feeling  of  weight  in  the 
pelvis.  The  bowels  are  sluggish,  alternating  with  diarrhoea ;  men- 
struation becomes  irregular,  profuse,  or  scanty  ;  pressure  symptoms 
may  be  complained  of;  sciatic  pain,  etc. ;  there  may  be  some  vesi- 
cal and  rectal  tenesmus. 

What  are  the  physical  signs? 

In  acute  cases  the  vagina  is  found  dry,  hot ;  localized  tenderness 
in  the  fornices,  usually  to  the  left  of  the  cervix.  Later,  an  exuda- 
tion mass,  tense,  elastic,  and  moderately  tender,  is  felt  bulging  into 
the  vagina  and  pushing  the  uterus  to  the  other  side.  The  exuda- 
tion mass  is  usually  lateral,  and  rarely  extends  above  the  brim  of 
the  pelvis,  as  it  does  in  peritonitis.  The  edge  of  the  broad  liga- 
ment may  be  felt  running  to  the  side  of  the  pelvis.  If  pus  forms, 
we  get  fluctuation  and  other  signs  of  an  abscess. 

From  what  should  pelvic  cellulitis  be  differentiated? 

Pelvic  peritonitis,  salpingitis,  pelvic  haematocele,  fibroids,  ovarian 
tumors,  faecal  impaction,  carcinoffta  of  rectum  high  up. 

What  is  the  differential  diagnosis  between  pelvic  peritonitis  and 
pelvic  cellulitis? 

Pelvic  Peritonitis.  Pelvic   Cellulitis. 

May  be  caused  by  inflammations  Rarely  caused  by  anything  but 
of  the  uterus,  ovaries,  and  labor  and  abortion  or  opera- 
tubes,  tions  on  the  cervix. 

Pain  severe.  Pain  less  severe. 

Temperature  not  high.  Temperature  high. 

Exudation  mass  not  apt  to  bulge  Exudation  mass  usually  bulges 
into  vagina,  and  is  usually  into  the  vagina,  and  is  usually 
bilateral.  unilateral. 

Vomiting.  Usually  no  vomiting. 

Suppuration  less  common.  Suppuration  more  common. 
In  the  acute  stage  it  may  be  very  difiicult  to  difl"erentiate. 

What  is  the  differential  diagnosis  between  salpingitis,  containing 
serum  or  pus,  and  pelvic  cellulitis. 
These  cases  were  formerly  supposed  to  be  cellulitis.     A  careful 
bimanual  examination  reveals  a   sausage-shaped   elastic  tumor  in 


PELVIC   CELLULITIS   OR   PARAMETRITIS.  195 

salpingitis,  extending  around  the  uterus,  sometimes  fluctuation. 
The  history  shows  recurrent  attacks  of  peritonitis.  The  patients 
are  usually  run  down  in  health,  while  in  cellulitis  they  are  usually 
perfectly  healthy.  In  salpingitis  the  mass  does  not  bulge  into  the 
vagina. 

What  is  the  differential  diagnosis  between  pelvic  cellulitis  and 
pelvic  hagmatocele  ? 

Pelvic  Cellulitis.  Pelvic  HBematocele. 

History  different  from   that  of     History   of  sharp    pain ;    symp- 
pelvic  hsematocele.  toms  of  internal  hemorrhage, 

pallor,  faintness,  collapse,  etc. 
(followed  by  a  sharp  attack  of 
peritonitis).  Physical  signs  of 
fluid  in  the  peritoneal  cavity. 

What  is  the  differential  diagnosis  between  pelvic  cellulitis  and 
fibroid  tumors? 

Pelvic   Cellulitis.  Fibroid   Tumors. 

History  of  inflammation  and  rapid     Slow  growth. 

formation  of  the  mass. 

Painful.  Not  painful  or  tender. 

Mass  fixed.  Moves  with  the  uterus. 

Less  well  defined.  More  defined. 

Menstruation  irregular.  Menorrhagia  increasing. 

What  is  the  differential  diagnosis  between  pelvic  cellulitis  and 
ovarian  cysts? 

Ovarian   Cysts.  Pelvic   Cellulitis. 

Slow,  painless  growth,  with  no  Rapid  and  painful,  with  history 

history  of  fever.  of  fever. 

No  disturbance  of  menstruation.  Disturbance  of  menstruation. 

Fluctuation.  No  fluctuation. 

How  would  you  differentiate  pelvic  cellulitis  from  carcinoma  of  the 
rectum  ? 

A  rectal  examination  will  reveal  the  character  of  the  mass,  and 
in  carcinoma  there  will  be  cachexia. 

What  complications  arise  with  cellulitis? 

Endometritis  ;  salpingitis  and  distortion  of  the  tubes  ;  enlarge- 
ments and  displacements  of  the  uterus  ;  destruction  of  the  ovaries  ; 
sterility. 


196    DISEASES  OF  THE  PELVIC  PERITONEUM  AND  FASCIA. 

What  is  the  prognosis  ? 

The  2^'^'opiosis  is  good,  the  time  is  uncertain.  If  suppuration 
takes  phice,  and  rupture  has  occurred  into  the  vagina  or  rectum,  or 
through  the  abdominal  wall,  the  prognosis  is  good.  If  it  ruptures 
into  the  ureters  or  bladder,  it  is  bad. 

What  is  the  treatment? 

Frophylactic. — Thorough  antiseptic  precaution. 

Curative. — (1)  Attempt  to  abort  by  complete  rest;  ice-bag  over 
the  site  of  the  severest  pain.  For  the  pain,  opium  suppositories. 
Give  Dover's  powder,  prolonged  hot  vaginal  douches,  and  poultices 
may  be  substituted  for  the  ice-bag. 

(2)  After  exudation  has  taken  place  promote  absorption  by  hot 
vaginal  douches,  2  quarts  twice  daily ;  hot  poultices  on  the  abdo- 
men.    Keep  up  the  general  nutrition  and  regulate  the  bowels. 

(3)  In  old  cases  resolvents:  vaginal  injections,  hot  sitz-baths, 
general  hot  baths,  pelvic  pack.  Counter-irritants :  blisters,  tr. 
of  iodine,  Paquelin  cautery.  Hydragogues :  Glycerin  tampons — 
boroglyceride  1,  alum  1,  chloral  2,  glycerin  15  parts. 

(4)  When  suppuration  take*  place,  open  wherever  it  points, 
and  drain. 

PELVIC  HEMATOCELE  AND  HEMATOMA. 

Define  these. 

A  pelvic  haematocele  is  an  effusion  of  blood  wholly  within  the 
pelvic  peritoneal  cavity,  and  which  may  be  enclosed  by  adhesions. 
A  pelvic  hsematoma  is  an  eiFusion  of  blood  outside  of  the  perito- 
neum into  the  cellular  tissue,  usually  between  the  folds  of  the 
broad  ligaments.  They  are  more  common  in  married  women  who 
have  borne  children  than  in  unmarried ;  not  infrequent  in  sterile 
married  women. 

Haematocele  is  almost  always  in  the  pouch  of  Douglas,  dis- 
placing the  uterus  forward ;  it  may  be  ante-uterine ;  haematoma  is 
almost  always  lateral. 

What  are  the  sources  of  the  effused  blood  ? 

lleflux  of  blood  from  the  uterus  and  Fallopian  tubes  at  time 
of  menstruation,  at  times  due  to  atresia  vagina?;  ruptured  tubal 
pregnancy  ;  ruptured  pelvic  vessels  ;  ruptured  cyst ;  excessive  blood 
from  a  ruptured  Graafian  follicle. 

The  blood  is  first  fluid,  high  up,  and  cannot  be  felt  well.     Later 


PELVIC   HEMATOCELE   AND    HEMATOMA.  197 

it  coagulates  and  pushes  the  uterus  forward  or  to  one  side.  Finally 
it  sets  up  peritonitis  (usually  twenty-four  hours  after  onset),  be- 
comes enclosed  by  adhesions,  and  may  go  on  to  suppuration  or  be 
absorbed. 

What  are  the  causes? 

Predispomig  :  marriage  state  ;  frequent  childbearing  ;  mid-men- 
strual period,  twenty  to  forty  years ;  profuse  menstruation ; 
anything  leading  to  congestion  of  the  pelvic  organs ;  diseases  of 
the  ovaries,  tubes,  or  pelvic  peritoneum  (adhesions)  ;  hard  work ; 
extra-uterine  pregnancy ;  varicose  veins  of  the  broad  ligaments ; 
atresia  in  the  genital  tract ;  diatheses — bleeders,  scurvy  ;  low  state 
of  the  system  ;  working  in  match-factories. 

Exciting :  Violence,  usually  the  result  of  coitus  during  men- 
struation ;  blows,  falls,  etc. ;  sudden  checking  of  menstrual  flow  by 
cold  or  emotion. 

The  majority  of  pelvic  haematoceles  are  due  to  extra-uterine 
pregnancy. 

What  are  the  symptoms  of  pelvic  haematocele  ? 

The  previous  history  usually  shows  poor  health  or  long-standing 
pelvic  disease,  such  as  chronic  pelvic  peritonitis.  Frequently  there 
is  a  history  of  having  missed  two  or  three  menstrual  periods.  The 
onset  is  usually  sudden,  ushered  in  by  sharp,  tearing  pain  in  the 
pelvic  region,  faintness.  collapse,  pallor,  feeble  and  rapid  pulse,  with 
all  the  other  symptoms  of  an  internal  hemorrhage.  The  tempera- 
ture is  normal  or  subnormal,  and  there  are  nausea  and  sometimes 
vomiting.  In  twenty-four  hours,  if  the  patient  does  not  die  from 
the  initial  hemorrhage  (usually  not),  peritonitis  is  set  up.  There 
is  a  sharp  chill,  rise  of  temperature,  etc.  Then  pressure  symptoms 
appear,  with  more  or  less  dysuria  and  painful  defecation.  There 
may  be  menorrhagia  or  the  flow  may  be  stopped. 

The  symjotoms  subside  in  a  few  days,  and  the  efl"used  blood  is 
slowly  absorbed.  If  suppuration  takes  place,  we  get  septic  symp- 
toms. 

What  are  the  symptoms  of  pelvic  hsematoma  ? 

This  usually  takes  place  at  a  menstrual  period  or  following  labor. 
It  may  result  from  a  ruptured  extra-uterine  pregnancy.  The  symp- 
toms are  much  less  severe.  Shock  and  pain  are  less  pronounced. 
The  effused  blood  forms  a  mass  in  the  exact  position  of  a  pelvic 
cellulitis.     The  uterus  is  pushed  high  up  over  the  symphysis,  and 


198    DISEASES  OF  THE  PELVIC  PERITONEUM  AND  FASCIA. 

there  are  pressure  symptoms  from  pressure  on  the  pelvic  nerves,  blad- 
der, and  rectum.     There  may  be  oedema  of  the  lower  limbs. 

What  are  the  physical  signs  of  hsematocele  and  haematoma? 

Hagmatocele  is  felt  as  a  tense,  elastic  mass,  usually  behind  the 
uterus,  pushing  it  well  forward  against  the  symphysis.  The  mass 
is  first  fluctuating,  then  hard.  Later  on  it  grows  rapidly  smaller, 
harder,  and  irregular  in  outline.  If  suppuration  takes  place,  it 
usually  ruptures  into  the  rectum.  HaDmatoma  is  felt  as  a  smaller 
mass,  usually  laterally,  between  the  folds  of  the  broad  ligaments, 
pushing  the  uterus  to  one  side.    It  is  less  tender  than  a  hgematocele. 

What  is  the  course,  duration,  and  termination? 

The  course  is  tedious.  If  the  flow  is  severe  in  a  hasmatocele, 
the  patient  may  die  at  once  from  shock  and  hemorrhage.  In  rup- 
tured tubal  pregnancies  the  j)'^'Off^osis  is  bad ;  in  mild  cases  it  is 
good,  but  patients  rarely  return  to  health.  It  may  end  in  disap- 
pearance, may  remain  stationary  for  years,  or  it  may  suppurate. 
The  prognosis  in  pelvic  hsemaloma  is  good. 

What  is  the  differential  diagnosis   between  pelvic  hsematocele 
and  the  following  diseases  ? 

Pelvic  Hsematocele.  Pelvic  Peritonitis. 

History  of  sudden   pain,  shock,  History  of  more  gradual  onset, 

fainting,  etc.,  followed  by  in-  with    signs    of    inflammation 

flammation.  from  the  beginning. 

Uterus  displaced.  Uterus  not  displaced,  but  fixed. 

Pelvic  Hsematocele.  Pelvic  Cellulitis. 

History  of  sudden  onset,  with  History  of  onset  following  labor, 
sharp  pain,  shock,  hemorrhage,  etc.,  and  with  inflammation 
etc.  from  the  outset. 

Tumor  at  first  soft,  later  irregular. 

Less  tender.  More  tender. 

Pelvic  Hsematocele.  Fibroid  Tumors. 

Rapid  and  sudden  development.  Slow  growth. 

History.  History. 

Sensitive.  Not  sensitive. 

Not  attached  to  the  uterus.  Attached  to  the  uterus. 


MENSTKUATION.  199 

Pelvic  Hdematocele.  Ovarian  Cysts. 

Sudden  onset.  Gradual  development. 

History.  History. 

Sensitive.  Less  sensitive. 

First  soft,  then  hard.  Fluctuating. 

What  is  the  differentiation  from  faecal  impaction? 

Be  sure  and  empty  the  rectum. 

What  from  carcinoma? 

Chronic  history  ;  uterus  not  displaced. 

What  is  the  treatment  of  pelvic  haematocele  ? 

Expectant :  Check  the  hemorrhage  ;  absolute  rest  in  bed  ;  ice 
on  abdomen  and  pressure  by  a  sand-bag  ;  hypodermic  of  morphine  ; 
open  the  bowels  early.  If  the  cause  of  the  hemorrhage  is  a  rup- 
tured extra-uterine  pregnancy,  open  the  abdomen  at  once  under  the 
antiseptic  preparations  for  any  laparotomy  ;  wash  out  the  effused 
blood ;  clamp  the  bleeding  points  and  tie  off  the  ruptured  tube  and 
broad  ligament,  and  remove ;  wash  out  the  abdomen  with  hot 
distilled  water;  insert  a  drainage-tube,  and  close  the  abdomen. 

In  the  second  stage  treat  the  symptoms  of  peritonitis. 

In  the  third  stage  promote  absorption  of  the  effusion  by  external 
and  internal  counter-irritants  and  hot  vaginal  injections.  If  sup- 
puration takes  place  and  points  in  the  vagina,  open  and  drain  here ; 
otherwise,  open  the  abdomen,  and,  if  possible,  remove  the  entire 
mass,  or  open  from  the  vagina  and  drain. 

What  is  the  treatment  for  pelvic  hsematoma? 

Absolute  rest  in  bed,  cold  on  the  abdomen,  opium ;  later,  hot 
douches,  poultices,  and  external  and  internal  counter-irritants. 
If  suppuration  takes  place,  open  and  drain  through  the  vagina 
or  throuoli  the  abdomen. 


'&' 


MENSTRUATION. 

What  is  meant  by  puberty  ?  and  what  by  the  menopause  or  cli- 
macteric ? 

Puberty  marks  the  transition  from  childhood  to  womanhood, 
when  the  several  organs  develop  and  menstruation  commences.  It 
marks  the  commencement  of  the  childbearing  period.  The  climac- 
teric period,  or  change  of  life,  is  that  period  when  menstruation  ceases 


200  DISORDERS    OF    MENSTRUATION. 

and  an  atrophy  of  the  pelvic  organs  takes  place.      Both  periods 
are  influenced  by  climate,  heredity,  and  habits  of  life. 

Puberty  usually  begins  at  about  the  fourteenth  year,  earlier  in 
hot  climates,  and  menstruation  ceases  usually  between  the  ages  of 
forty-two  and  forty-five.  During  both  these  periods  the  entire  sys- 
tem feels  the  change,  and  various  pathological  phenomena  may  be 
developed.     The  climacteric  period  usually  lasts  about  two  years. 

What  are  phenomena  of  normal  menstruation  ? 

The  chief  feature  of  menstruation  is  the  periodical  discharge  of 
blood  from  the  uterine  cavity  (every  twenty-eight  days),  which  lasts 
normally  between  four  and  five  days.  The  amount  varies  in  indi- 
viduals. This  discharge  of  blood  depends  upon  the  presence  of 
the  ovaries,*  and  is  supposed  to  coincide  with  the  rupture  of  a 
Graafian  follicle.  The  superficial  and  glandular  epithelium  of  the 
mucous  membrane  lining  of  the  cavity  of  the  uterus  undergoes 
fatty  degeneration  once  a  month,  disintegrates,  and  is  cast  off". 
The  exposed  capillaries  beneath  are  readily  ruptured,  and  cause 
the  bleeding.  When  the  congestion  of  the  pelvic  organs  is  relieved, 
the  flow  ceases.  The  lining  membrane  of  the  uterus  is  now  repro- 
duced by  a  proliferation  of  the  cells  beneath  the  former  layer. 

DISORDERS  OF  MENSTRUATION. 

What  are  the  disorders  of  menstruation  ? 

Amenorrhoea,  monorrhagia,  metrorrhagia,  dysmenorrhoea,  vicari- 
ous menstruation.  All  of  these  are  symptoms  of  more  or  less  well- 
defined  diseases,  and  not  diseases  themselves. 

AmenorrhcBa. 

What  is  meant  by  amenorrhoea?  and  what  are  its  causes,  prog- 
nosis, and  treatment? 

Amenorrhoea  is  the  absence  of  menstruation  occurring  between 
the  ages  of  puberty  and  the  menopause.  During  the  periods  of 
pregnancy  and  lactation  it  is  purely  physiological. 

What  are  the  causes? 

Local. — Non-development  of  the  generative  organs ;  atrophy 
of  the  uterus  and  ovaries ;  local  inflammation  of  the  ovaries ; 
occlusion  of  some  portion  of  the  genital  tract. 

Constitutional. — Debilitating    diseases,    such    as    phthisis,   etc. ; 

*  According  to  Lawson  Tait,  the  Fallopian  tubes  have  more  influence. 


DISORDERS   OF   MENSTRUATION.  201 

anaemia,  chlorosis ;  plethora ;  mental  emotions ;  cold  and  wet,  as 
wetting  the  feet  during  menstruation  ;  poor  food ;  changes  of  cli- 
mate, as  seen  in  immigrants  ;  obesity. 

What  is  the  prognosis? 

This  depends  upon  the  exciting  causes.  If  these  can  be  removed 
the  jyrocfnosis  is  good.  Amenorrhoea  due  to  non-development  of 
the  generative  organs  is  usually  incurable. 

What  is  the  treatment? 

When  due  to  non-development  of  the  generative  organs  and 
absence  of  the  ovaries,  nothing  can  be  done.  When  due  to  ansemia 
and  chlorosis,  give  Blaud's  pills,  2  t.  i.  d.pc.  ;  regulate  bowels  ;  good 
food ;  fresh  air  and  exercise.  Permanganate  of  potash  and  the 
black  oxide  of  manganese  are  recommended.  A  pill  containing 
iron  and  aloes  is  sometimes  very  effectual.  When  due  to  imperfect 
development  and  with  presence  of  the  ovaries,  tonics  of  quinine, 
iron,  and  arsenic ;  hot  douches  ;  boroglyceride  tampons  ;  electricity, 
faradic  current.  For  the  acute  suppression  of  menstruation  due  to 
exposure  to  cold  and  wet.  hot-water  foot-baths  and  hot  sitz-baths ; 
aconite  internally.  When  due  to  phthisis  and  other  debilitating 
diseases  the  treatment  is  that  of  the  disease. 

Menorrhagia  and  Metrorrhagia. 

Define  menorrhagia  and  metrorrhagia. 

Menorrhagia  means  a  profuse  menstruation  ;  metrorrhagia  means 
a  discharge  of  blood  from  the  generative  tract  between  menstrual 
periods. 

What  is  the  etiology  ? 

Menorrhagia  and  metrorrhagia  nearly  always  indicate  local  dis- 
ease of  the  lining  membrane  of  the  uterus,  endometritis,  fibroid 
tumors  of  the  uterus  and  polypi,  subinvolution,  chronic  metritis, 
retained  secundines  after  abortion,  salpingo-obphoritis,  carcinoma, 
sarcoma  and  laceration  of  cervix  ;  other  causes,  acting  indirectly, 
are  cardiac  disease,  engorgement  of  the  portal  circulation,  certain 
wasting  diseases,  and  malaria,  menopause,  scurvy,  haemophilia. 

What  is  the  treatment? 

The  causes  will  indicate  the  treatment,  but  there  will  usually 
be  found  coexisting  diseases  of  the  endometrium,  requiring  local 
interference — i.  e.  curetting.     The  patient  is  placed  in  Sims's  posi- 


202  DYSMENOERHCEA. 

tion,  Sims's  speculum  introduced,  the  cervix  dilated  with  Peaslee's 
and  Goodell's  dilators,  and  the  endometrium  thoroughly  scraped  out 
with  a  Thomas  dull  curette  or  a  Sims  curette.  Strict  antisepsis 
must  be  observed.  The  uterus  is  then  thoroughly  irrigated  with 
hot  1  :  100  carbolic,  to  which  iodine  may  be  added  if  the  hemor- 
rhage is  profuse.  The  uterine  cavity  is  then  painted  with  iodized 
phenol  (iodine  gr.  Ix,  carbolic  acid  5J),  and  an  iodoform  gauze 
tampon  introduced.  Drugs,  such  as  ergot,  hydrastis  Canadensis, 
and  cannabis  Indica,  are  sometimes  useful  in  decreasing  the  flow. 
Ergot  and  hydrastis  should  be  administered  for  several  days  after 
a  curetting. 

Fibroids  may  require  to  be  removed  thoroughly,  or  the  removal 
of  the  ovaries  and  tubes.  Carcinoma  and  inflammations  of  the 
ovaries  and  tubes  require  their  own  treatment.  Retained  secun- 
dines  must  be  removed  by  curetting  as  described. 

Vicarious  'Menstruation. 

What  is  meant  by  this? 

A  discharge  of  blood  from  some  part  of  the  body  other  than  the 
uterus  at  the  menstrual  epoch.  It  may  be  associated  with  amenor- 
rhoea  and  scanty  menstruation,  and  indicates  a  watery  condition 
of  the  blood,  with  a  constitutional  tendency  to  bleed.  The  blood 
may  come  from  the  nose,  mouth,  throat,  JDreasts,  open  sores,  or 
wounds. 

What  is  the  treatment? 

When  this  is  associated  with  amenorrhoea,  the  cure  of  this  will 
usually  stop  the  vicarious  menstruation.  If  not  troublesome,  no 
special  treatment  is  indicated. 

Dysmenorrhcea. 

Define  dysmenorrhoea. 

The  term  dysmenorrhoea  signifies  an  abnormal  amount  of  pain 
at  the  time  of  the  menstrual  epoch,  occurring  just  before,  during, 
and  just  after  menstruation.  It  is  a  symptom,  and  not  a  disease 
by  itself. 

How  is  dysmenorrhoea  classified  for  convenience? 

The  varieties  of  painful  menstruation  mentioned  are  neuralgic, 
ovarian.,  congestive,  obstructive,  and  memhranous ;  but  they  cannot 
be  distinctly  separated,  being  often  combined. 


DISORDERS   OF   MENSTRUATION.  203 

Give  the  etiology,  symptoms,  prognosis,  and  treatment  of  neuralgic 
dysmenorrhoea. 

Etiology. — No  pathological  changes  can  be  detected  in  the  pelvic 
organs.  The  same  causes  producing  neuralgia  in  other  parts  of 
the  body  may  act  on  the  pelvic  organs — enervating  habits,  anaemia, 
or  anything  depressing  the  system  ;  hysteria,  masturbation,  rheuma- 
tism, and  gout ;  lacerations  of  the  cervix.  Sometimes  no  cause  can 
be  found.     It  is  often  associated  with  other  varieties. 

Symptoms. — The  pain  is  of  a  sharp,  fixed  character  or  lancinat- 
ing and  colicky.  It  may  be  referred  to  the  uterus  or  ovaries  or 
rarely  to  some  distant  part  of  the  body.  The  pain  usually  appears 
before  the  flow,  and  continues  less  severe  during  the  discharge,  but 
it  may  stop  with  the  onset  of  the  flow.     It  varies  in  intensity. 

During  the  intermenstrual  period  the  patients  frequently  have 
neuralgia  elsewhere. 

Prognosis. — If  the  patients  can  be  built  up  in  health  and  adopt 
good  treatment  for  a  cure,  recovery  is  probable.  Parturition  is 
said  sometimes  to  produce  a  cure. 

Treatment. — This  is  indicated  by  the  predisposing  cause.  The 
same  treatment  as  for  neuralgia  in  other  parts  of  the  body.  Ton- 
ics, complete  change  of  mode  of  life  and  climate,  fresh  air,  exer- 
cise, sound  introduced  just  before  the  period,  or  rapid  dilatation, 
electricity.  For  the  pain,  suppositories  of  cannabis  Indica  and 
belladonna  or  of  opium  may  be  given.  The  tine,  of  piscidia  in  tt\^xx 
doses  is  highly  recommended.  Hot  sitz-baths.  Hayden's  vibur- 
num compound  is  excellent. 

Give  the  etiology,  symptoms,  and  treatment  of  ovarian  dysmen- 
orrhoea. 

Etiology. — It  is  supposed  to  be  due  to  disease  of  the  ovaries,  but 
there  is  often  grave  disease  of  the  ovaries  without  any  painful 
menstruation. 

Symptoms.— Voin  in  the  intervals  between  the  menses,  coming  on 
a  few  days  before  the  flow  and  diminishing  with  it.  The  pain  is 
of  a  dull,  aching  character,  accompanied  by  tenderness  over  the 
region  of  the  ovaries.  There  may  be  nervous  phenomena  and  dis- 
turbances in  the  tracts. 

Treatment. — For  ovaritis  build  up  general  health  ;  Battey's  ope- 
ration as  a  last  resort. 

Define  congestive  dysmenorrhoea. 

This  form  is  characterized  by  an  excessive  congestion  of  the  ute- 


204  DYSMENORRHCEA. 

rus  and  appendages  during  menstruation,  owing  to  an  abnormal  state 
of  these  organs,  which  gives  rise  to  pain. 

What  is  the  etiology? 

Peri  uterine  inflammation,  salpingitis,  displacements  of  the  ute- 
rus, uterine  fibroids,  endometritis,  chronic  metritis,  exposure  to  cold 
and  wet  during  menstruation,  plethora. 

What  are  the  symptoms? 

Sudden  pain  at  the  menstrual  period.  This  may  last  during  the 
whole  period  or  become  gradually  less.  It  is  usually  accompanied 
by  a  decrease  or  stoppage  of  the  flow,  and  some  constitutional  dis- 
turbances— fever,  headache,  nausea,  constipation,  rapid  pulse,  etc. 

What  is  the  prognosis? 

Good  if  the  cause  can  be  removed. 

What  is  the  treatment?         ^ 

Correct  the  causes.  When  due  to  exposure  to  cold  and  wet 
during  a  period,  have  the  patient  soak  her  feet  in  a  hot  mustard 
foot-bath  ;  wrap  up  in  blankets  and  go  to  bed ;  aid  perspiration  by 
diaphoretics ;  make  hot  applications  to  the  pelvis.  In  the  inter- 
menstrual period  give  hot  vaginal  douches  ;  glycerin  tampons  ;  scar- 
ify the  cervix  ;  prevent  tight  lacing  and  hanging  heavy  skirts  on 
the  waist.  For  the  pain  the  same  remedies  as  for  the  neuralgic 
form  may  be  used. 

Define  obstructive  dysmenorrhoea. 

This  form  of  dysmenorrhoea  is  due  to  an  obstruction  to  the  flow 
which  may  be  situated  in  the  cervix  or  vagina.  It  is  not  nearly  as 
common  as  was  supposed. 

What  is  its  etiology? 

Contraction  of  cervical  canal,  congenital,  or  acquired  by  the  ap- 
plication of  strong  caustics,  labor,  or  operations  on  the  cervix.  The 
stenosis  may  be  at  the  external  or  internal  os :  the  latter  is  much 
more  commonly  a  cause  of  pain  than  the  former.  Additional 
causes  are  flexions  of  the  uterus,  fibroids  and  polypi,  stenosis  of 
the  vagina,  long  conical  cervix,  spasmodic  contractions  of  the 
internal  os. 

What  are  the  symptoms? 

Pain  of  a  colicky  expulsive  character,  situated  in  the  pelvis  and 
accompanied  by  the  passage  of  clots.     This  is  due  to  the  collection 


DISORDEES   OF   MENSTRUATION.  205 

of  blood  distending  the  uterine  cavity  until  labor-like  pains  are 
excited.  Uterine  contractions  finally  overcome  the  obstruction, 
and  there  is  a  gush  of  blood  and  clots.  This  may  be  repeated  until 
the  flow  comes.  The  internal  os  in  these  cases  is  often  found  hyper- 
aesthetic  on  the  passage  of  a  sound. 

What  is  the  treatment? 

This  consists  in  removing  the  cause  of  the  obstruction  ;  mechani- 
cal dilatation  with  Peaslee's  graduated  dilators  and  steel  branched 
dilators  ;  vaginal  strictures  may  be  treated  by  dilatation  or  divis- 
ion. 

Describe  the  method  of  dilating  the  cervix. 

The  patient  may  be  placed  in  Sims's  or  the  lithotomy  position 
on  the  edge  of  a  table.  A  Sims  speculum  is  introduced,  and  the 
parts  thoroughly  irrigated  with  1  :  2000  bichloride.  The  anterior 
lip  of  the  cervix  is  grasped  with  a  pair  of  bullet  forceps  and  drawn 
down.  The  curve  of  the  uterus  having  been  previously  ascertained, 
the  smallest  sized  sound  is  introduced,  and  allowed  to  remain  a  few 
minutes ;  then  a  larger  sized  is  used,  etc. ;  finally  a  steel  branched 
dilator  is  introduced  and  expanded.  The  canal  may  be  kept  patent 
by  means  of  an  Outerbridge  wire  stem,  or  by  the  passage  of  a 
graduated  sound  every  few  weeks.  An  anaesthetic  is  not  always 
necessary  in  these  cases. 

Define  membranous  dysmenorrhoea. 

Membranous  dysmenorrhoea  is  the  expulsion  of  the  lining  mem- 
brane of  the  uterine  cavity,  whole  or  in  pieces,  at  the  menstrual 
period. 

What  is  its  etiology? 

The  true  cause  of  this  affection  is  not  known.  It  may  be  associ- 
ated with  metritis  or  endometritis,  and  is  usually  found  in  cases  of 
poor  general  health.  The  membrane  consists  of  the  superficial 
layer  of  the  endometrium,  with  an  excess  of  the  round  cells  and 
fibres.  It  is  usually  triangular  in  form,  its  internal  surface  being 
smooth  and  its  external  shaggy.  It  presents  numerous  perforations, 
the  openings  of  the  utricular  glands.  The  blood  collects  under 
this  membrane  and  dissects  it  off. 

What  are  the  symptoms? 

Severe  pain   at  the   commencement  of  the   flow,  increasing  in 


206  ELECTRICITY   IN   GYNECOLOGY. 

severity  until  the  membrane  is  discharged.  This  usually  takes 
place  on  the  third  day,  and  the  pain  ceases.  The  flow  is  usually 
profuse. 

For  what  is  this  liable  to  be  mistaken? 

Early  abortion.  It  can  be  differentiated  from  this  by  its  repeti- 
tion, by  the  absence  of  chorionic  villi,  and  by  the  absence  of  the 
symptoms  of  pregnancy. 

What  is  the  treatment? 

It  is  very  difficult  to  cure.  Dilatation  and  curetting,  followed 
by  painting  the  endometrium  with  iodized  phenol  or  iodine,  may 
be  resorted  to.  For  the  pain  give  hot  sitz-baths  and  hot  applica- 
tions to  the  pelvis,  together  with  the  drugs  mentioned  for  neuralgic 
dysmenorrhoea.  ^ 

ELEOTRIOITY  IN  GYNECOLOGY. 

What  apparatus  is  required? 

1.  Galvanic  Battery. — Made  up  of  at  least  30  cells,  with  large 
elements  (per  ex. :  zinc  and  carbon  plates  6X9  inches  in  a  solution 
of  bichromate  of  potash  and  sulphuric  acid). 

Accessories  to  Galvanic  Battery. — Rheostat^  to  regulate  the 
strength  of  the  current  by  regulating  the  amount  of  resistance  in 
the  circuit ;  milliampere  meter,  to  indicate  the  strength  of  the 
current. 

2.  Faradic  Battery. — The  most  convenient  is  one  in  which  the 
primary  current  is  generated  by  a  single  dry  cell. 

3.  Conducting  Wires.  4.  Electrodes. — Large  flat  electrode  with 
sponge  or  soft  clay  surfaces  for  the  abdomen,  and  a  variety  of 
electrodes  with  insulated  stems  and  cylindrical,  globular,  or  sharp- 
pointed  metal  or  carbon  tips  for  vaginal  and  intra-uterine  use  or 
for  electro-puncture. 

What  are  the  therapeutic  effects  ? 

Relief  of  pain  (mild  faradic  current)  ;  stimulation  of  growth 
and  function  in  the  uterus  and  ovaries  (medium  faradic  current)  ; 
hajmostatic  (faradic  or  the  positive  pole  of  the  galvanic  battery)  ; 
absorption  of  inflammatory  masses  and  adhesions  (negative  gal- 
vanic pole)  ;  destruction  of  vitality  in  the  foetus  in  extra-uterine 


ELECTRICITY   IN   GYNECOLOGY.  207 

gestation    (galvanic    current) ;    alterative   effect   upon    neoplasms, 
especially  fibro-myoma  (galvanic  current). 

What  are  the  indications  for  the  use  of  electricity  ? 

Acute  Injlammations. — Mild  faradization,  and,  as  a  rule,  not  in- 
tra-uterine. 

Adhesions  and  Exudations. — Negative  pole  in  the  vagina  and 
a  galvanic  current  of  fifteen  to  fifty  milliamperes  passed  for  ten 
minutes.  Galvano-puncture  has  been  recommended,  but  is  less 
free  from  danger. 

Amenorrlioia  and  Dysmenorrhoea. — Spinal  galvanization,  one 
pole  over  the  nape  of  the  neck  and  one  over  the  sacrum  ;  or  the 
faradic  current,  with  one  pole  over  the  lumbar  vertebrae  and  one 
over  the  hypogastrium  ;  or  one  pole  over  the  hypogastrium  and 
one  in  the  cavity  of  the  uterus,  the  current  being  either  faradic 
or  galvanic  (negative  pole  in  uterus). 

Cervical  and  Corporeal  Endometritis. — The  negative  galvanic  pole 
is  in  the  uterine  cavity,  and  a  current  of  twenty  or  thirty  milliam- 
peres is  passed  for  twenty  minutes  three  times  a  week.  For  chronic 
cases  the  strength  of  the  current  may  be  gradually  increased  to 
one  hundred  or  even  two  hundred  milliamperes,  but  the  sittings 
should  be  very  short. 

Menorrhagia  and  Metrorrhagia. — The  mild  faradic  current,  with 
one  pole  in  the  uterus,  sittings  daily  for  twenty  or  thirty  minutes, 
is  quite  effective.  In  extreme  cases  the  positive  electrode  of  the 
galvanic  battery  may  be  placed  in  the  uterine  cavity,  and  a  current 
passed  strong  enough  to  act  as  a  cauterant. 

What  is  the  value  of  electricity  in  uterine  fibro-myoma  ? 

This  is  the  chief  condition  for  which  the  use  of  electricity  has 
been  praised  in  gynecology  ;  it  is  also  the  one  for  which  very  many 
eminent  practitioners  consider  electricity  valueless.  The  details 
of  the  treatment  have  already  been  given.  The  best  results  are 
obtained  in  the  submucous  variety,  in  which  the  hemorrhage  may 
be  well  controlled,  extrusion  favored,  and  the  growth  often  arrested. 
In  the  interstitial  form  similar  results  may  sometimes  be  obtained, 
but  in  the  subserous  form  benefit  is  rare  and  the  risks  are  greater. 

Describe  the  method  of  administering  electricity  in  ovarian  irri- 
tation. 

A  large  ball  electrode,  positive,  is  placed  in  the  vagina,  and  a 


208  ELECTRICITY   IN   GYNECOLOGY. 

galvanic  current  of  ten  milliamperes  is  passed  for  twenty  minutes 
twice  a  week. 

What  are  the  results  of  the  use  of  electricity  in  gynecology  ? 

In  a  certain  proportion  of  cases  in  the  above  classes  the  results 
are  excellent ;  in  other  eases  the  results  are  discouraging.  While 
not  a  panacea,  it  is  still  a  legitimate  and  desirable  means  of  treat- 
ment in  gynecological  diseases. 


INDEX. 


A. 

Amenorrhoea,  200 

Applications  through  the   speculum, 
126,  127 

B. 

Battey's  operation,  184 
Bladder,  anatomy,  77,  78 
diseases,  79 

C. 

Caruncle,  urethral,  56 
Catarrh  of  the  cervix,  137 
Cervix,  carcinoma,  161. 
symptoms,  162 
treatment,  163 
operative,  164 
catarrh,  137 

treatment,  138 
erosions,  136 
laceration,  139 
Coccyodynia,  56 
Colpocystotomy,  80 
Colporrhaphy,  76 
Cord,  hydrocele,  49 
Curette,  37-39 
Cystitis,  79,  80 
Cystocele,  64 

I>. 

Dilatable  tubes,  37 
Dilators,  35,  36 
Dysmenorrhoea,  202 
varieties,  202-205 


Electricity,  206 

14— Gyn. 


E. 


Endometritis,  128 
acute,  128 
chronic,  cervical,  135,  137 

corporeal,  129 
fungous,  131 

treatment,  132-134 
glandular,  130 
interstitial,  130 
mixed,  130 
Enterocele,  64 
Examination,  18 
bimanual,  21,  22 
physical,  18-20 
rational,  18 
rectal,  22,  23 
External  organs  of  generation,  40 
anatomy,  40-45 
diseases,  45 
Extra-uterine  pregnancy,  187 
varieties,  187 

F. 

Fallopian  tubes,  auatomy,  170,  171 
Fistulas,  80 

operations,  82-84 

vesico-uterine,  81 

vesico-vaginal,  81 

G. 

Gynecological  disease,  causation,  17, 
18 
diagnosis,  18 

H. 

Hsematosalpinx,  186 
Hsematothorax,  62 
Hysterectomy,  abdominal,  164 
vaginal,  1G4 

209 


210 


INDEX. 


Laceration  of  the  cervix,  139 

operations  for,  142-145 

site,  140 

symptoms,  141 

treatment,  142 
Lacerations  of  the  perineum,  67 

causes,  68 

operations,  69-71 

symptoms,  69 

varieties,  68 

M. 

Menorrhagia,  201 
Menstruation,  199 

disorders  of,  200 

normal,  200 

vicarious,  202 
Metritis,  118 

acute,  118 

chronic,  119-122,  124,  125 
of  the  cervix,  121 
operative  treatment,  125 
Metrorrhagia,  201 

o. 

Oophorectomy,  184 
Ovaries,  abscess,  177 

anatomy,  170,  171 

apoplexy,  175 

atrophy,  173 

dis])lacements,  173 

hernia,  174 

inflammations,  175 

malformations,  172 

neoplasms,  177 
cysts,  178 

diagnosis,  179-181 
treatni(>nt,  181 

prolapse,  174 
Ovariotomy,  1S2 
Ovaritis,  acute,  175 

chronic,  176 

P. 

Parametritis,  192-195 
Parovarian  cysts,  181 
Pelvic  cellulitis,  192-195 

Uoor,  65-67 

hai'matocele,  196 


Pelvic  hematocele,  diagnosis,  198 
symptoms,  197 
treatment,  199 
hsematoma,  196 
diagnosis,  198 
symptoms,  197 
treatment,  199 
lacerations,  67 
peritoneum,  188,  189 
peritonitis,  188,  190  192 
Perineal  body,  65-67 
Perineorrhaphy,  71-76 
Pessaries,  110,  111 
Position,  Sims's,  23 
Prolapsus  urethrfe,  57 
Pyosalpinx,  186 


Eectocele,  64 


K. 


S. 


Salpingitis,  185 
Salpingo-oophorectomy,  187 
Sims's  tenaculum,  28 
Sounds,  steel  and  hard-rubber,  34,  35 

uterine,  29 
Specula,  23 

bivalve,  27,  28 

Cleveland's,  26 

Fergusson's,  26 
introduction,  26 

Simon's,  26 

Sims's,  23 

introduction,  24,  25 
Staffordshire  knot,  183 

T. 

Tait's  operation,  184 
Tents,  32,  33 

introduction,  34 
Trachelorrhaphy,  143  145 

u. 

Urethra,  anatomy,  77 

diseases,  79 
Urethritis,  79 
Uterine  catheter,  40 

sound,  29,  30 
introduction,  31 
Uterus,  amputation,  169 


INDEX. 


211 


uterus,  anatomy,  84-90 
anteflexion,  104,  105 
anteversion,  102,  103 
atrophy,  96,  97 
descent,  114,  115 

displacements,  97,  98,  101,  102,  117 
hypertrophy,  95,  96 
inversion,  165,  167 
complete,  166 
diagnosis,  167 
partial,  166 
treatment,  168,  169 
malformations,  90-95 
neoplasms,  146 
adenoma,  165 
carcinoma,  161 
fibro-cystic  tumor,  157 
fibro-myomata,  146 
symptoms,  151-154 
treatment,  154 

operative,  155-157 
varieties,  147-150 
polypus,  158 

symptoms,  159,  160 
treatment,  160 
sarcoma,  165 
prolapse.  114,  115 

treatment,  116,  117 
retroflexion,  106-109 

operative  treatment,  113,  114 
treatment,  109,  110 
retroversion,  106-109 

operative  treatment,  113,  114 


V. 


Vagina,  cysts,  61 
diseases  of,  57 


Vagina,  displacements,  63 

malformations,  61,  62 

prolapse,  63 

ulcers,  61 
Vaginismus,  55 
Vaginitis,  57 

catarrhal,  58,  59 

children,  57 

cystic,  61 

follicular,  61,  62 

gonorrhceal,  59,  60 

ulcerative,  60 
Volsella,  28 
Vulva,  cutaneous  attections,  53 

cysts,  46 

diseases,  45 

eczema,  52 

elephantiasis,  49 

heematocele,  47 

hemorrhage,  47 

hernia,  46 

hyperesthesia,  55 

malformations,  45 

nervous  aff"ections,  53,  54 

oedema,  47 

parasites,  53 

tumors,  45,  46 

ulcers,  53 

varicocele,  47 
Vulvitis,  49 

catarrhal,  49,  50 

diphtheritic,  51 

follicular,  51 

gangrenous,  52 

gonorrhceal,  50 

phlegmonous,  51 
Vulvo-vagiual  glands,  abscess,  48 

cyst,  48' 


RGlll 

Bratenahl 


B73 


